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Presented  in  honor  of 

William  R.  Laughlin,  D.  0. 

by 
Mrs.  William  R,  Laughlin 


I 


COLLEGE    OF    OSTEOPATHIC     PHYSICIANS 
AND  SURGEONS  •   LOS  ANGELES,  CALIFORNIA 


999(d®99®9(»(9(d®9®9(»(»®®9®®(»®(»9®9(»®99($®$tt 


» 


WILLIAM  ROSS  LAUGHLIN 

M.S.  -  D.O. 

Los  ANGELES,  California 


Digitized  by  the  Internet  Archive 

in  2007  with  funding  from 

IVIicrosoft  Corporation 


http://www.archive.org/details/diseasesofwomenmOOclariala 


Diseases  of  Womeni 


A  MANUAL  OF  GYNECOLOGY  DESIGNED  FOR  THE 

USE  OF  OSTEOPATHIC  STUDENTS  AND 

PRACTITIONERS 


BY 

M0%  CLARK,  D.  O.. 

Professor  of  Gynecology  and  Obstetrics  in  the  American 

School  of  Osteopathy;  Member  Operating  Staff 

A.  T.  Still  Infirmary. 


k 


SECOND  EDITION. 

Thoroughly  Revised,  with  111  Illustrations. 


monotypei)  by 

Journal  Fiunting  Company, 

kirk8ville,  mo. 

1904 


Copyrighted  by 

M.  E.  Clark, 

1904. 


PREFACE  TO  SECOND  EDITION. 


The  very  gratifying  reception  accorded  to  the  first  edition 
of  this  work  has  prompted  me  to  make  the  second  edition  still 
more  acceptable  to  the  profession. 

I  have  rewritten  a  great  deal  of  the  subject  matter  and  the 
other  subjects  have  been  much  enlarged.  In  addition  many  new 
sections  and  interpolations  have  been  added. 

Much  attention  has  been  paid  to  the  causes  and  treatment 
of  female  diseases  from  the  bony  lesion  standpoint.  Surgical 
gynecology  has  been  purposely  left  out. 

The  most  of  the  illustrations  are  original,  while  the  proper 
credit  is  given  for  those  copied. 

M.  E.  CLARK.  D.  O. 
Kirksville,  Mo.,  September,  1£04. 


DISEASES   OF   WOMEN. 


CONTENTS. 


INTRODUCTION. 

DEVELOPMENT. 

ANATOMY: — External  Genitalia;  Vagina;  Uterus;  Ovaries; 
Tubes;  Urethra;  Bladder;  Pelvic  Peritoneum;  Pelvic  Floor; 
Pelvic  Connective  Tissue;  Bony  Pelvis. 

GENERAL  CAUSES  OF  DISEASE. 

METHODS  OF  EXAMINATION. 

DISEASES  OF  THE  VULVA. 

AFFECTIONS  OF  THE  UTERUS :— Relations ;  Normal  Position; 
Support's;  Varieties  of  Displacement;  Prolapsus  Uteri;  Re- 
placement; Anteversion;  Anteflexion;  Retroversion;  Retro- 
flexion; Inversion. 

TUMORS  OF  THE  UTERUS. 

LACERATION  OF  THE  CERVIX. 

INFLAMMATION  OF  THE  UTERUS :— Endometritis ;  Metritis; 
Perimetritis. 

PHYSIOLOGICAL  PERIODS:— Infancy  ;  Puberty  ;  Maturity  ; 
Menopause;  Senility. 

GENERAL  DISORDERS  OF  MENSTRUATION:— Amenorrhea; 
Scanty  Menstruation;  Dysmenorrhea;  Menorrhagia;  Vicar- 
ious Menstruation. 


CONTENTS.  b 

DISEASES  OF  FALLOPIAN  TUBES. 

OVARIAN   DISEASES. 

REFLEX  DISORDERS. 

MISCELLANEOUS  AFFECTIONS :— Sterility ;  Masturbation ;  Abor- 
tion; Ectopic  Gestation;  Mammary  Diseases;  Hernia; 
Hemorrhoids;  Sciatica;  Chlorosis;  Milk  Leg;  Skin  Eruption; 
Leucorrhea  in  Children;  Diseases  of  Rectum;   Rheumatism. 


DISEASES    OF    WOMEN. 


INTRODUCTION. 


GYNECOLOGY  is  the  science  which  treats  of  the  diseases 
PECULIAR  TO  WOMEN.  Since  woman  possesses  organs  which  man 
has  not,  and  as  the  role  she  plays,  both  physiological  and  social, 
differs  from  that  played  by  man,  we  would  expect  to  find  her 
afflicted  with  a  number  of  diseases  peculiar  to  herself,  which 
depend  on  her  make-up,  function  and  habits.  As  far  back  as 
history  carries  us  we  find  mentioned  certain  diseases  peculiar  to 
women.  Instruments  have  been  found,  such  as  sounds  and 
various  forms  of  specula,  which  indicate  that  uterine  diseases 
were  recognized  and  that  attempts  were  made  to  correct  them 
even  at  that  early  date. 

Prior  to  the  time  of  Sims,  the  practice  of  gynecology  con- 
sisted, for  the  most  part,  in  replacing  the  malposed  uterus,  ad- 
justing pessaries,  and  the  application  of  various  medicinal  agents 
to  the  cervix  and  uterine  canal.  Within  the  last  decade  gyne- 
cology has  developed  into  a  science  distinctly  surgical,  when 
viewed  from  the  standpoint  of  an  abdominal  surgeon  or  the  so- 
called  specialist.  All  chronic  conditions  are  looked  upon  as 
surgical,  and  such  operations  as  curettage,  ovariotomy  or  some 
form  of  laparotomy  is  performed  for  the  most  trivial  ailments, 
while  in  some,  the  operation  is  performed  as  an  experiment  or 
for  the  purpose  of  diagnosis.  Shortening  of  the  uterine  liga- 
ments and  operations  on  the  vagina  and  pelvic  floor,  such  as 
colporrhaphy  and  perineorraphy,  are  the  operations  that  are 
most  frequently  performed. 

During  this  period  Dr.  A.  T.  Still,  noting  the  prevalence  of 


INTRODUCTION.  1 

and  tendency  to,  surgical  operations,  reasoned  that  "a  woman 

WAS  NOT  MADE  TO  BE  MAIMED  BY  USELESS  SURGICAL  EXPERI- 
MENTS." He  began  to  study  the  human  body,  its  mehcanism, 
parts,  and  functions  of  all  these  parts,  but  particularly  the  pel- 
vic viscera.  As  a  result  of  this  study,  a  new  sj'stem  of  thera- 
peutics in  general  was  evolved,  which  he  called  osteopathy;  while 
a  new  system  of  gjmecology  in  particular,  was  given  to  the  world, 
marking  the  beginning  of  an  epoch,  for  the  relief  and  cure  of 
female  diseases,  greater  than  any  pre^dous  one  marked  by  any 
new  mode  of  treatment. 

The  basic  principle  of  osteopathy  in  general,  and  osteopathic 
gynecology  in  particular  is,  that  a  perfectly  adjusted  body 
IS  necessary  to  health;  and  that  a  perfect  adjustment  of 

THE  PARTS  CONCERNED  IN  THE  FORMATION  OF  THE  FEMALE  SEX- 
UAL  APPARATUS,  IS    NECESSARY   TO   THEIR    PERFECT   FUNCTIONING; 

this  perfect  adjustment  existing,  health  prevails. 

Nerve  force  must  be  distributed  to  every  part  of  the 
HUMAN  BODY.  The  BLOOD  must  be  kept  in  motion  all  the 
TIME,  not  lagging  for  an  instant,  or  its  vitality  lowers  and  a  pre- 
disposition to  disease  follows. 

Dr.  Still  reasoned  that  a  derangement  of  the  frame- 
work of  the  body  affected  the  structure  and  function  of  the  vis- 
cera directly  or  indirectly  in  relation  with  the  deranged  part; 
these  effects  interfering  with  normal  nerve  supply  to,  and  cir- 
culation through,  these  structures  and  viscera.  These  derange- 
ments of  the  framework  consist  of  partial  or  complete  disloca- 
tion of  vertebrae,  especially  the  lumbar,  and  of  the  sacrum, 
coccyx,  innominata,  ribs  and  hip  bones.  Visceral  lesions,  such 
as  displacements  of  the  intestines,  and  the  uterus  with  its  at- 
tachments and  appendages,  are  recognized  as  important  causes 
of  interference  with  distribution  of  blood  and  nerve  force. 


S  DISEASES    OF    WOMEN. 

These  theories  have  been  put  into  practice  by  osteopathic 
physicians  and  proven  beyond  successful  contradiction,  thus 
marking  a  new  era  in  gynecological  therapeutics. 

Formerly,  strange  theories  were  advanced  as  to  the  causes 
of  female  diseases.  Some  found  the  explanation  of  all  uterine 
diseases  in  congestion,  others  in  displacements;  one  declared 
"leucorrhea  to  be  the  great  evil;"  another,  ulcerations  and  gran- 
ulations. Most  of  the  modern  teachers  are  inclined  to  trace  them 
to  inflammation.  Necessarily  as  a  result  of  these  varied  ideas, 
exclusive  therapeutists  developed.  Congestion  was  treated  by 
blood  letting,  displacements  by  various  mechanical  devices, 
while  others  directed  all  their  attention  to  the  curing  of  the 
leucorrhea. 

On  account  of  ignorance  of  the  function  of  the  female 
GENITAL  ORGANS  and  their  relation  to  disease,  I  think  they  h9,ve  been 
maltreated  more  than  any  other  part  of  the  body.  One  extreme 
has  followed  another;  experiment  after  experiment  has  been  per- 
formed, and  the  latest  fad  or  experiment  is  operation.  If  the 
patient  has  painful  menstruation  or  a  chronic  abdominal  pain 
an  operation  is  at  once  advised.  I  am  glad  to  say  that  the  os- 
teopath does  not  have  to  resort  to  such  for  relief  in  the  vast  ma- 
jority of  cases,  but  relieves  the  sufferer  wdthout  unsexing  her  by 
an  operation.  Thus  from  an  uncertain  experimental  condi- 
tion, osteopathy  steps  forth  a  certain  and  perfect  science.  I 
sincerely  believe  that  the  science  of  osteopathy  is  the  only  ration^ 
al  and  natural  way  of  treating  ailments  peculiar  to  women. 

THE  OSTEOPATH  views  these  diseases  from  an  entirely 
different  and  new  standpoint;  at  least  the  method  of  correct- 
ing them  is  new.  While  some  of  the  causes  usually  mentioned 
are  recognized,  other  causes  more  potent,  which  belong  to  the 
REALM   of   osteopathy,   are  regarded   as   the   most  important, 


INTRODUCTION.  9 

and  by  removing  these,  permanent  cures  result.  The  osteopath- 
ic idea  depends  on  proper  adjustment  of  both  the  internal 
organs  of  generation  and  the  bony  framework  in  which  they  are 
located.  Any  displacement  of  either  one  tends  to  interfere  with 
the  normal  distribution  of  blood  and  nerve  force,  both  of 
which  are  requisite  to  perfect  health.  Pure  blood  is  moving 
biood,  and  it  cannot  be  pure  and  be  stagnant  at  the  same  timeo 
If  the  blood  is  circulating  properly,  health  must  ensue;  that 
is,  our  object  in  treating  these  diseases  is  to  relieve  obstructions 
both  mechanical  and  vaso-motor,  to  the  proper  circulation  of 
the  blood. 

The  mechanical  obstructions  come  from  visceral  displace- 
ments; the  vaso-motor  disturbance,  from  some  mal-adjust- 
ment  of  structures  in  relation  with,  origin  of,  or  along  course  of 
the  nerves,  either  cerebro-spinal  or  sympathetic,  supplying  the 
uterus.  Bony  lesions,  muscular  contractures  or  relaxation, 
and  abnormal  conditions  of  the  ligaments,  produce  most  of  the 
vaso-motor  disturbances. 

LACK  OF  CARE  on  the  part  of  the  patient,  such  as  ex- 
posure during  menstruation,  and  overwork,  both  physical  and 
mental,  at  the  time  of  puberty,  are  common  exciting  causes 
of  female  diseases.  At  the  menstrual  period  there  are  vascular 
and  nervous  changes  taking  place  which,  if  interfered  with,  will 
be  the  cause  of  various  chronic  uterine  troubles.  During  puberty, 
the  development  of  the  uterus  and  its  appendages  takes  place, 
and  if  the  nerve  force  that  should  be  used  for  their  development 
is  directed  into  other  channels,  by  mental  or  physical  over-work, 
the  pelvic  organs  suffer. 

PHYSIOLOGY  The  proper  performance  of  the  function 
of  the  parts  is  necessary  to  health,  and  any  condition  perverting 
the  normal  functioning  would  result  in    disease.      In  this  class 


10  DISEASES    OF    WOMEN. 

are  included  the  barren,  and  especially  those  who  deliberately 
prevent  or  destroy  the  products  of  conception.  The  function 
of  these  organs  is  reproduction,  and  if  the  function  is  not  per- 
formed there  will  be  a  disturbance  of  the  health  of  the  organs; 
for  instance,  fibroid  tumors  are  usually  found  in  nullipara  above 
the  age  of  thirty;  again,  those  who  deliberately  prevent  con- 
ception by  the  various  artificial  means,  interfere  with  nature 
and  impair  the  whole  nervous  system.  Nature  will  not  stand 
tampering  with  without  rebelling,  and  there  is  a  penalty  for  every 
infringement.  The  least  interference  with  her  laws  results  in 
disorders  which  vary  with  the  amount  of  interference. 

IN  THE  TREATMENT  of  diseases  peculiar  to  women,  the 
perverted  physiology  is  relieved  in  two  ways;  first,  proper  care 
on  the  part  of  the  patient;  second,  correction  of  anatomical 
derangements.  If  the  bony  framework  is  properly  adjusted 
health  will  follow  in  most  cases. 

The  bony  lesion  is  usually  primary,  sometimes  secondary. 
Abuse  of  function  will  result  in  anatomical  changes.  By  the 
treatment  and  correction  of  these  anatomical  derangements, 
which  is  hard  to  do  in  some  cases,  some  good  effect  on  the  viscus 
that  is  diseased  or  abused  can  be  obtained.  For  example,  ovarian 
colic  will  produce  contracture  of  muscles  in  the  back.  By  over- 
coming this  contracture  by  inhibition,  which  is  not  possible  in 
many  cases,  the  pain  can  be  relieved.  The  trouble  is,  in  such 
cases,  the  effect  not  the  cause  is  treated,  and  on  this  account 
little  can  be  done  with  such  contractures,  and  that  only  tempo- 
rarily. 

The  ANATOMY  of  the  organs  themselves;  the  neighboring 
structures  and  tissues;  the  nerve  supply  to  and  from  the  organ; 
the  blood  supply  and  lymphatic  circulation  are  considered.  To 
the  osteopath  the  bony  framework  in  which  the  pelvic   viscera 


INTRODUCTION.  11 

are  located,  is  the  most  important ;  and  on  this  account  special 
attention  should  be  given  to  the  lesions  affecting  the  sacrum, 
iliac  bones,  lumbar  vertebrae  and  the  coccyx.  In  addition, 
uterine  displacements  should  be  corrected,  since  obstruction  to 
nerve  force,  congestion,  or  even  inflammation  results  from  them, 
which  things  cause  varied  and  complex  troubles;  contractured 
muscles  relaxed,  whether  the  result  of  thermic  influence  or  of  a 
bony  lesion ;  and  lesions  affecting  nerve  centers  of  the  uterus  are 
adjusted,  since  such  impair  their  function.  The  nerve  centers 
need  very  little  artificial  stimulation  if  their  connection  wdth  the 
brain  and  uterus  is  not  interrupted,  since  the  body  is  a  self- 
running  MACHINE.  The  rules  of  hygiene  and  dietetics  should  be 
followed  in  these  as  well  as  in  other  diseases;  that  is,  advise  the 
patient  to  take  plenty  of  outdoor  exercise  and  permit  her  to  eat 
anything  that  agrees  with  her,  but  caution  her  against  excesses 
along  this  line. 


12  DISEASES    OF    WOMEN. 


DEVELOPMENT  OF  THE  FEMALE  GENITAL  ORGANS. 


SOME  KNOWLEDGE  of  the  origin  and  development  of  the 
female  genital  organs  is  necessary  to  a  proper  understanding  of 
the  conditions  in  which  they  have  failed  to  attain  the  normal; 
as  in  errors  of  development  such  as  are  exemplified  in  uterus 
bicornis,  infantile  ovary  or  uterus  and  atresia  of  some  parts  of 
the  genital  tract. 

THE  DATE  of  first  appearance  of  the  genital  organs  is 
about  the  sixth  week.  The  first  organs  to  appear  are  the 
Wolffian  ducts,  one  on  each  side  of  the  body.  Originally  they 
are  solid  cords  but  afterward  become  hollowed  out  so  as  to  form 
tubes.  Shortly  after  the  Wolffian  ducts  have  begun  to  develop, 
the  Wolffian  bodies  appear.  From  the  external  surface  of  each 
Wolffian  body  a  structure  develops,  known  as  the  genital  gland, 
which  subsequently  becomes  either  a  testicle  or  an  ovary.  The 
two  sexes  cannot  be  differentiated  before  the  eighth  week.  At  about 
the  tenth  week  the  external  genital  organs  show  a  change  mak- 
ing it  possible  to  differentiate  between  the  sexes.  In  the  male,  com- 
mencing at  that  time,  the  slight  prominence  which  marked  the 
site  of  the  external  organs  enlarges  quite  rapidly.  In  the  female, 
the  upper  end  of  the  Wolffian  body  is  attached  to  the  diaphragm, 
the  lower,  to  the  inguinal  region  by  a  ligament,  which  ultimately 
becomes  the  round  ligament  of  the  uterus.  This  is  of  interest 
because  it  shows  that  the  round  ligaments  are  not  in  reality  lig- 
aments, but  consist  of  tissue  almost  identical  with  that  forming 
the  uterus.  From  the  Wolffian  body  is  also  developed  the  or- 
gan of  RosenmuUer  or  the  parovarium. 


DEVELOPMENT. 


13 


rev 


Fig.  1. — Development  of  thegenito-urinary  Hystera.  1,  2,  bladder;  3,  clitoris;  4,  sinus 

uro-genitalis;  5,  Muller's    duets;  6,  14.  Wolffian  bodies;  7,   11,  Wolffian   duets; 

8,  ovaries;  9,  ends  of  Wolffian  duets;    10,   opening  of  ducts  into  the  sinus 

uro-genitalin;    i2,  urethra;  13,  urachus. 

OVARIES.  The  point  to  be  considered  in  the  development 
of  the  ovary,  is  its  descent.  Originally,  the  ovary  is  develop- 
ed in  connection  with  the  kidneys,  and  as  it  increases  in  size  it 
descends,  and  on  this  account  the  blood  vessels  and  nerve  fibers 
supplying  it  are  lengthened.  In  case  of  ovarian  diseases  then, 
we  would  expect  the  lesion  to  be  in  the  lower  dorsal  region.  The 
ovary  undergoes  great  changes  in  shape;  at  first  it  is  an  elon- 


14  DISEASES   OF    WOMEN. 

gated  FLATTENED  body,  but  later  it  changes  its  shape  so  that  a 
transverse  section  has  the  appearance  of  a  bean,  and  finally  it 
becomes  almond  shaped. 

In  the  early  stages  the  ovary  is  represented  by  a  mass  of 
cells  developed  from  the  peritoneal  covering  of  the  Wolffian 
body,  but  soon  a  protuberance  of  connective  tissue  enters  from 
behind  into  this  cell  mass.  From  this  we  find  that  the  elements 
entering  into  the  structure  of  the  ovary  are  the  cells  which  form 
the  parenchyma  or  glandular  element,  and  the  connective  tissue 
or  stroma.  From  this  cell  mass  the  ova  are  developed.  Their 
number  is  enormous,  it  having  been  estimated  that  the  tw© 
ovaries  together  contain  above  seventy-two  thousand. 

THE  MULLERIAN  DUCTS.  Shortly  after  the  appearance 
of  the  Wolffian  bodies,  there  appears  about  the  twelfth  week, 
a  funnel-shaped  invagination  from  the  endothelium  of  the  peri- 
toneum at  the  inner  side  of  the  Wolffian  bodies,  which  develops 
into  the  MuUerian  ducts,  and  is  fastened  to  these  bodies  by  a 
mesentery.  After  the  bodies  disappear ,  this  invaginated  portion 
becomes  attached  to  the  posterior  abdominal  wall  and  finally, 
in  the  fully  developed  body,  it  forms  a  part  of  the  broad  liga- 
ments of  the  uterus. 

From  that  part  of  the  Mullerian  ducts  which  lies  above  the 
insertion  of  the  round  ligaments  of  the  uterus,  are  formed  the 
Fallopian  tubes;  from  that  part  below,  together  with  the  lower 
end  of  the  Wolffian  duct,  the  genital  cord  or  uterus.  The  tissue 
that  separates  these  ducts  is  absorbed  and  the  septum  disappears 
in  the  lower  two-thirds,  thus  forming  the  cavity  of  the  uterus. 
The  insertion  of  the  round  ligament  indicates  the  point  of  divi- 
sion between  the  tube  and  the  uterus.  The  fifteenth  week  wit- 
nesses the  fusion  of  the  uterine  horns  and  the  formation  of  the 
cervix,  enlargement  of  the  perineum  and   development  of  the 


15 


DEVKIiOPMENT. 


vagina.  Sometimes  these  Mullerian  ducts  fail  to  coalesce,  that 
is,  the  partition  is  not  absorbed,  and  from  this  arises  the  condi- 
tion of  uterus  bicornis  or  uterus  bifida.      In  the  new  born  child 


16 


DISEASES    OF    WOMEN. 


the  cervix  is  nearly   twice  as  long  as  the  body    of  the  uterus 


Fkj.  3. — Uterus  bicoriiis 

and  its  walls  very  much  thicker.  Sometimes  this  condition 
exists  after  puberty  and  the  name  "infantile  uterus"  has  been 
applied  to  such  condition.  If  on  local  examination  of  a  woman 
above  the  age  of  puberty  the  cervix  is  very  small,  it  is  a  diseased 
condition  dependent  upon  error  in  development,  or  a  lesion  re- 
sulting from  an  accident  at  puberty  which  affected  the  nutrition 
center  for  the  uterus. 

During  the  first  ten  or  twelve  years  of  a  child's  life  the 
uterus  is  physiologically  dormant;  but  at  the  approach  of  men- 
struation the  organ  undergoes  great  vascular  changes  with  a 
marked  increase  in  size,  which  continues  until  the  rest  of  the 
body  has  attained  its  limit  of  growth.  In  Fig.  4  the  female  ex- 
ternal organs  of  generation  of  an  adult  are  shown. 


AX  ATOMY. 


17 


Fig.  4. — The  vulva,  the  external  female  or^tins 
of  generation.    (Gray.) 


18  DISEASES    OF    WOMEN. 


THE  ANATOMY. 


DIVISION  OF  THE  GENITALIA.  The  genitalia  are  divided 
into  the  external  and  internal  organs.  The  former  with  the 
vagina,  form  the  organs  of  copulation;  the  latter,  the  repro- 
ductive organs  proper.  To  the  external  genitals  belong  the 
mons  Veneris,  the  vulva  and  the  vagina;  to  the  internal,  the 
uterus.  Fallopian  tubes  and  the  ovaries.  The  vagina  is  really 
the  connecting  link  between  the  external  and  internal  genera- 
tive organs  and  belongs  to  neither,  but  is  usually  classed  with 
the  external  organs. 

THE  MONS  VENERIS  is  a  cushion  of  fat  which  covers  the 
pubes.  It  is  covered  with  short  crisp  hairs  which  serve  to  pro- 
tect from  injuries  and  perspiration,  the  more  delicate  parts 
which  lie  posterior  to  it.  In  cases  of  threatened  abortion  or 
hemorrhage  from  the  uterus,  stimulation  produced  by  a  quick 
jerk  of  these  hairs  of  the  mons  Veneris,  will  usually  stop  the  abor- 
tion or  hemorrhage  by  causing  contraction  of  the  circular  mus- 
cle fibers  of  the  cervix.  There  are  numerous  nervous  fibrils 
which  terminate  in  the  mons  Veneris,  also  a  part  of  the  round 
ligaments.     It  also  contains  many  sebaceous  and  sweat  glands. 

THE  LABIA  MAJORA.  The  labia  majora  are  two  masses 
of  tissue  which  surround  the  entrance  to  the  vagina,  uniting 
behind  just  anterior  to  the  anus  in  the  posterior  commissure  or 
fourchet,  and  in  front  in  the  mons  Veneris;  being  analagous  to 
the  scrotum  in  the  male.  They  are  less  prominent  after  child- 
bearing,  and  during  old  age  they  often  present  a  shrivelled 
appearance.  These  folds  are  covered  with  short  hairs  which 
are  continuous  with  those  covering  the  mons  Veneris.     Numerous 


ANATOMY. 


19 


sebaceous  glands  are  found  which  secrete  a  fluid  which  serves  to 
moisten  and  lubricate  the  internal  surface. 


Fig.  5. — Kxteriial  jjrtMiit.ilia  of  nmltiparous 
woman,  lifbia  in  contact.    (Williams). 

The  inner  surface  is  rose-color  and  forms  a  transition  from 
skin  to  mucous  membrane.  In  the  adult  nulliparous  woman, 
the  lower  edges  of  the  labia  majora  are  in  contact;  cover  all  the 
other  parts  of  the  vulva  and  form  a  line  running  in  an  antero- 
posterior direction,  called  the  rima  pudendi.  In  a  parous  woman 
these  lips  are  .slightly  separated.  The  pudendal  sac  also  lies  un- 
der this  covering,  and  contains  erectile  fibers. 

The  CANAL  OF  NucK,  which  is  a  prolongation  of  the  peri- 
toneum ACCOMPANYING  the  round  ligament,  is  found  under  the 
pudendal  sac,  which  sac  is  attached  to  the  external  inguinal  ring. 
In  the  aged  there  sometimes  exists  a  flabby   condition  of  these 


20 


DISEASES    OF    WOMEN. 


greater  lips,  and  separation  results,  leaving  the  nymphse,  as  well 
as  a  part  of  the  vaginal  canal,  exposed. 

The  point  of  union  posteriorly,  is  just  anterior  to  the  anus 
and  is  very  frequently  lacerated  during  the  first  labor,  unless 
care  is  used  by  the  accoucheur.  On  either  side  the  round  liga- 
ments are  inserted  into  upper  part  of  lips. 

THE  LABIA  MINORA  OR  NYMPHS.  The  labia  minora 
are  two  triangular  folds  of  fine  skin  which  lie  between  the  labia 
majora,  becoming  much  more  prominent  anteriorly.  They  are 
also  called   nymphae   because  they  were  supposed  to    direct    the 


inim,M^p 


Fit;  ti  — Exti'i'iiiil  jjenitalia  t)f  multiparoiis  wo- 
mjui,  labia  spread  apart.     (Williainsj 

course  of  the  stream  of  urine.  Anteriorh^  they  bifurcate  form- 
ing two  folds;  one  going  above  the  clitoris  and  forming  its 
prepuce;  the  other  below    forming    the     frenulum.     Posteriorly 


ANATOMY.  21 

they  sometimes  extend  to  the  median  hne,  thus  forming  a  com- 
plete ring  inside;  but  more  commonly  they  extend  but  half 
way  back  blending  with  the  labia  majora.  When  they  extend 
to  the  median  line  they  assist  in  the  formation  of  the  fourchet. 
Sometimes  there  exists  a  non-developed  condition  of  these  two 
folds,  as  a  result  of  which  they  do  not  separate  or  in  other  cases 
as  a  result  of  inflammation,  adhesion  occurs,  both  of  which  result 
in  a  hooded  clitoris,  which  condition  is  a  cause  of  various  re- 
flex nervous  disorders.  "In  the  Bush-women  of  South  Africa 
the  labia  minora  become  very  long  and  extend  in  some  cases, 
as  far  as  the  knees;  this  condition  being  known  as  the  Hot- 
tentot apron." 

In  the  NEW  BORN  child,  the  labia  minora  extend  beyond 
the  labia  majora  on  account  of  the  non-developed  condition  of 
the  greater  lips.  The  lesser  lips  in  the  adult  are  very  copiously 
supplied  with  sebaceous  and  mucous  glands,  and  during  sexual 
excitement,  they  taking  part  in  the  sexual  act  and  being  abundant- 
ly supplied  with  sensory  nerves,  their  secretions  are  markedly 
increased. 

The  labia  majora  contain  no  fat  but  here  are  located  large 
VENOUS  plexuses  and  bulb-shaped  terminal  nerve  organs.  In 
case  of  masturbation,  the  lesser  lips  are  very  red  and  irritable. 
There  is  often  discovered  on  them  a  yellowish  deposit.  They 
are  usually  hypertrophied  in  cases  of  chronic  masturbation  while 
the  greater  lips  are  atrophied.  Sometimes  hystero-epilepsy  re- 
sults from  irritation  or  inflammation  of  these  lips;  such  being 
the  condition  in  a  case  treated  by  the  author  in  which  the  least 
irritation  would  bring  on  an  attack  and  in  which  case  they  were 
hypertrophied  and  hypersensitive. 

THE  CLITORIS.  The  clitoris  is  an  erectile  organ  which  is 
the  homologue  of  the  male  organ,  the  penis,  but  differs  from  it  in 


22  DISEASES    OF    WOMEN. 

that  it  does  not  possess  a  corpus  spongiosum  and  is  not  tunnelled 
by  the  urethra.  It  is  composed  of  two  corpora  cavernosa  and 
the  GLANS  CLiTORiDis.  It  is  held  in  position  by  a  suspensory  liga- 
ment, attaching  it  to  the  lower  border  of  the  symphysis  pubis. 
It  forms  a  landmark  for  the  location  of  the  meatus  urinarius 
which  is  located  about  one  inch  posterior  to  it. 

During  the  non-erectile  state,  only  the  glans  clitoridis  is 
visible;  but  during  the  erectile  stage  the  two  crura  which  unite 
to  form  the  clitoris  proper,  can  be  clearly  outlined  and  have  the 
appearance  of  an  inverted  "V."  The  glans  clitoridis  contains 
papillae  occupied  by  arterial  tufts,  and  the  special  peculiar  nerve 
endings,  the  genital  corpuscles.  There  is  an  intimate  con- 
nection between  the  clitoris  and  the  nipples;  both  being  com- 
posed of  erectile  tissue.  Stimulation  of  the  nipples  will  cause 
contraction  of  the  uterus  and  erection  of  the  clitoris.  The  cli- 
toris is  the  chief  seat  of  voluptuous  sensation  and  in  cases  in  which 
masturbation  has  been  practiced  the  glans  clitoridis  \\dll  be  found 
red,  irritable  and  sometimes  inflamed. 

A  recent  writer  claims  that  the  meatus  urinarius  instead 
of  the  clitoris  is  the  seat  of  voluptuous  sensation.  He  says, 
"  In  the  male  the  orgasm  results  from  the  passing  of  jets  of  semen 
over  the  mucous  membrane  of  the  urethral  canal;  in  the  female, 
by  jets  of  mucus  from  the  neck  of  the  bladder  through  the  urethra." 

As  mentioned  above,  this  organ  may  be  hooded;  adhesions 
may  exist;  or  it  may  be  in  a  condition  of  non-development, 
either  of  which  may  seriously  interfere  with  the  nerve  force  of 
the  body.  Stimulation  of  this  organ  produces  contraction  of 
the  cervix  uteri,  while  inhibition  produces  relaxation.  This 
is  explained  by  the  fact  that  the  pudic  nerve  which  supplies  the 
clitoris,  connects  with  and  is  derived  from  the  same  source  that 
the  nerves  which  supply  the  cervix,  viz:  the  sacral  nerves  from 


ANATOMY. 


23 


the  sacral  segments  of  the  spinal  cord.  Since  the  cerebro- 
spinal nerves  predominate  in  the  cervix,  and  the  sympathetic 
in  the  fundus  and  body  of  the  uterus,  the  above  connection  is 
the  more  readily  understood.  Advantage  is  taken  of  this  by 
the  osteopath  in  the  treatment  of  dysmenorrhea  due  to  the  con- 
traction of  the  cervix  lessening  the  calibre  of  the  os;  also  the 
first  stage  of  labor,  inhibition  of  the  clitoris  in  both  cases 
dilating  the  os.  Inhibition  at  the  sacro-iliac  synchondroses 
has  a  similar  effect :  the  sacral  nerves  being  directly  reached  at 
these  points. 

The  BLOOD  supply  of  the  clitoris  comes  from  the  internal 
pudic  by  way  of  the  dorsal  arteries  of  the  clitoris  and  the  artery 


Vestibular 
bulbs 


--Vagina 


Fig.   7. — Preparjition   tfihowing  clitoris   and  its    vascular 
supply.    (Modified  from  Olirobak  and  Rosthorn,  by  Williams.) 

of  the  corpus  cavernosum.      The  veins    accompany    the  arter- 
ies; the  DORSAL  vein  of  the  clitoris  being  the  principal  one.  This 


24  DISEASES    OF    WOMEN. 

vein  is  the  homologue  of  the  dorsal  vein  of  the  penis  and  is  one 
of  the  principal  factors  in  erection. 

The  nerve  supply  comes  from  the  dorsal  nerve  of  the  cli- 
toris which  is  the  termination  of  the  pudic  nerve.  This  nerve 
terminates  in  corpuscles  and  very  abundantly  supplies  the  or- 
gan. These  terminal  nerves  are  relatively  better  developed  and 
are  found  in  greater  numbers,  than  the  corresponding  ones  in 
the  penis.  Lesions  of  the  lower  dorsal  region  will  affect  this 
nerve,  causing  either  stimulation  or  inhibition,  that  is,  increas- 
ing or  decreasing,  even  destroying,  sexual  desire. 

Williams  says"  About  the  middle  of  the  last  century  Baker 
Brown  proposed  the  amputation  of  the  clitoris  as  a  panacea  for 
nearly  all  ails  to  which  women  are  subject,  and  for  a  short  time 
the  operation  of  clitoridectomy  enjoyed  a  marked  vogue  but  has 
since  become  completely  abandoned.'* 

Among  many  of  the  aboriginal  races  the  same  operation 
has  been  performed  from  time  immemorial  as  a  religious  rite  and 
was  designated  as  "girl  circumcision." 

VESTIBULE.  The  vestibule  is  a  triangular  space  situated  be- 
tween the  lesser  lips,  bounded  anteriorly  by  the  crura  of  the  clitoris 
and  posteriorly  by  the  opening  of  the  vagina.  Some  writers 
include  with  it  the  fossa  navicularis,  and  define  the  vestibule  as 
an  almond-shaped  area  which  is  enclosed  between  the  labia  minora 
and  extends  from  the  clitoris  to  the  fourchet.  The  fossa  navi- 
cularis is  seldom  observed  in  parous  women  since  it  is  usually 
obliterated  by  childbirth.  Near  the  center  is  found  the  meatus 
urinarius,  and  just  below  the  meatus  is  a  little  mucous  elevation, 
which  is  a  guide  to  the  introduction  of  the  catheter  when  in 
spection  is  not  used. 

Extending  from  the  clitoris  along  either  side  of  the  vesti- 
bule are  two  large  oblong   masses  about   one  inch  in  length. 


ANATOMY. 


25 


consisting  of  a  plexus  of  veins  enclosed  in  a  thin  layer  of  fibrous 
membrane.  These  bodies  are  called  bulbi  vestibuli  or  bulbs 
OF  THE  VAGINA,  and  are  analogous  to  the  bulb  of  the  corpus 
spongiosum  of  the  male;  they  being  regarded  as  the  cleft  homo- 
logue  of  the  corpus  spongiosum.  The  constrictor  vaginal 
MUSCLES  lie  in  relation  with  these  bulbs  and  by  their  contrac- 
tion, as  during  sexual  excitement,  these  venous  plexuses  are 
compressed  and  the  tissues  become  erect.  Repeated  sexual 
excitement  causes  a  weakening  of  these  muscles  and  the  walls 
of  these  veins  are  dilated  and  diseased  conditions  follow.  These 
are  shown  in  Fig.  8. 


Fig.  8. — The  bulbs  of  vestibule,  n.  Bulb  of  vestibule;  b,  muscular  tissue  of  va- 
gina; c,  (1,  e,  f,  the  clirori!*  ninl  niuxclew;  g.  h.  i,  k,  1,  m,  n,  veins  of  tlie  nympliae 
and  clitoris  communicating  witli  tlie  cpigiistric  tind   obstructor  veins.     (Jewett). 

Sometimes  these  veins    become  enlarged  from  other  causes 
and  a  tumor  is  formed,   which    becomes  very  painful  in  some 


26 


DISEASES    OF    WOMEN. 


cases.     Mucous  follicles  are  located  over  the  vestibule  and  secrete 
mucus  very  freely  under  any  persistent  irritation. 

BARTHOUN'S  GLANDS.  On  either  side  of  the  commence- 
ment of  the  vagina  and  behind  the  hymen  are  found  two  bean- 
shaped,  round  or  oblong  bodies,  which  are  analogous  to  Cow- 
per's  glands  in  the  male;  these  are  called  the  glands  of  Bartholin 
and  are  shown  in  Fig.  9.     They  are  muco-serous  glands  and  pour 


,^    ,    ^\f!W      VULVO.V«OIN/>L 

1    XA\ :       «"'^'' 


Fig.  9. — The  vulvo  TaKinal  gland  or  gland  of  Bartholin.    The  dotted  line   indi- 
cates the  limits  of  the  bulbs  of  the  vagina.     (Testut). 

their  secretions  upon  the  mucous  membrane  by  long  slender 
ducts  which  open  just  external  to  the  hymen.  These  ducts  often 
harbor  gonococci  which  gain  access  to  the  gland  and  set  up  sup- 
puration. The  greater  lip  becomes  distended  with  pus  and  if 
not  opened  up,  will  break  on  its  inner  and  lower  aspect.  Such 
abscesses  are  common  in  prostitutes.  Other  cases  of  abscess 
of    Bartholin's   glands   result   from   trauma. 

TheTglands   constantly   secrete     a     glairy    fluid,    but   dur- 


ANATOMY.  27 

ing  sexual  excitement  this  secretion  is  enormously  increased. 
They  are  supposed  to  be  affected  in  cases  of  sexual  debility  and 
in  cases  in  which  there  is  a  flabby  condition  of  the  vulva  or  lower 
abdominal  wall.  Sometimes  in  cases  of  difficult  labor,  inhi- 
bition OF  THESE  GLANDS  and  the  nerves  in  relation,  will  cause 
dilatation  of  the  vagina  by  relaxing  the  perineum.  The  sphinc- 
ter vagina  and  levator  ani  muscles  are  the  principal  factors 
that  control  the  tone  of  the  pelvic  floor. 

There  are  numerous  small  mucous  secreting  glands  called 
glandulae  vestibulares  minores  which  open  into  the  vesti- 
bule. These  when  normal,  keep  the  vulva  quite  thoroughly 
moistened  and  lubricated.  Their  secretion,  like  that  of  Bartho- 
lin's glands,  is  increased  by  sexual  excitement. 

HYMEN.  The  hymen  is  a  membranous  fold  containing 
a  few  connective  tissue  fibers,  blood  vessels  and  nerve  filaments, 
which  closes  to  a  greater  or  lesser  extent,  the  entrance  to  the 
vagina,  or  ostium  vaginae.  This  membrane  is  usually  perforated 
by  one  or  more  openings  through  which  escapes  the  menstrual 
flow.  The  opening  is  usually  crescentic  in  shape  with  the  con- 
cavity looking  upward  Sometimes  it  is  circular,  or  the  mem- 
brane may  be  perforated  with  many  small  openings,  to  which 
is  given  the  name  of  cribiform  hymen. 

In  the  new  born  baby  the  opening  is  very  small  and  some- 
times obscure.  If  an  imperforate  condition  exists,  and  it 
causes  no  particular  disturbance,  wait  until  puberty  before 
rupturing  it,  but  if  nervous  symptoms  develop  without  any  other 
apparent  cause,  the  membrane  should  be  perforated. 

In  structure  it  is  the  same  as  the  walls  of  the  vagina,  with 
some  modification  as  mentioned  above,  since  the  vaginal  walls 
unite  below  to  form  this  membrane.     Several  types,  regarding 


28 


DISEASES   OF   WOMEN. 


thickness,  have  been  observed,  ranging  from  a  dehcate  struc- 
ture resembHng  a  spider's  web  to  a  fleshy  Hgamento-cartilagin- 


Fig.  10. — Different  forms  of  hymens  . 

ous  membrane.  In  some  it  ruptures  on  the  slightest  pressure, 
in  others  an  operation,  by  which  an  artificial  opening  is  made, 
is  necessary  before  a  digital  examination  is  possible. 


ANATOMY.  29 

Sometimes  at  puberty  the  hymen  is  imperforate  and  amen- 
orrhea or  rather  concealed  menstruation  exists. 

After,  rupture  the  edges  cicatrize  and  the  hymen  becomes 
permanently  divided  into  several  portions,  called  carunculae 
MYRTIFORMES.  The  extent  of  rupture  varies  with  the  struc- 
ture of  it.  It  is  generally  believed  by  the  laity  that  the  rupture 
is  associated  with  hemorrhage,  but  this  is  by  no  means  always 
the  case,  though  in  rare  instances  there  is  a  profuse  hemorrhage 
resulting  in  anemia.  The  hymen  is  usually  ruptured  at  first 
coition,  and  on  this  accovuit  it  is  of  medico-legal  interest;  how- 
ever, it  may  persist  after  copulation,  so  its  condition  cannot  be 
considered  as  a  reliable  test  of  virginity. 

Care  should  be  taken  in  the  examination  of  a  young  girl 
that  the  hymen  be  not  ruptured;  in  fact,  it  is  seldom  necessary 
to  make  a  local  examination  of  a  virgin,  and  should  be  avoided 
as  long  as  possible.  Labor  usually  destroys  the  hymen  and  all 
that  remains  are  several  protuberances,  which  form  a  serrated 
ring  around  the  ostium  vaginae.  These  remains,  whether  due  to 
childbirth,  coition  or  forcible  examination,  do  not  always  heal 
readily  but  remain  irritable  and  produce  vaginismus  and  dys- 
pareunia.  Forms  of  nervous  affections  also  are  attributed  to 
this  pathological  condition  of  the  hymen. 

THE  FOURCHET.  The  fourchet  is  a  thin  fold  of  skin  form- 
ed by  the  junction  of  the  posterior  ends  of  the  labia  majora; 
sometimes  the  minora.  It  encloses  a  boat-shaped  depression, 
which  is  called  the  fossa  navicularis.  The  point  of  interest  re- 
garding it  is,  that  it  is  either  very  badly  bruised,  or  lacerated  at 
the  first  parturition. 

THE  VAGINA.  The  vagina  is  a  musculo-membranous 
CANAL  which  connects  the  uterus  with  the  vulva.  It  is  con- 
tinuous above  with  the  cervix,  with  which  it  forms  the   vaginal 


30  DISEASES   OF    WOMEN. 

vault  or  fornlces,  and  below,  with  the  hymen.  The  fornices 
are  divided  into  the  lateral,  anterior  and  posterior  from  their 
relation  to  the  cervix  uteri.  Their  size  depends  on  position, 
length  and  thickness  of  the  cervix;  degree  of  distention  or  bal- 
looning of  the  vagina;  and  the  presence  or  absence  of  growths. 
The  AXIS  OF  THE  VAGINA  forms  an  angle  of  about  sixty  degrees 
with  the  horizon,  and  in  its  lower  portion  is  about  parallel  with 
the  conjugate  diameter  of  the  brim  of  the  pelvis,  while  the  upper 
end  presents  a  concavity  corresponding  to  the  curve  of  the  sac- 
rum. It  has  two  walls,  one  anterior  and  one  posterior,  which 
are  held  in  apposition,  principally,  by  the  muscles  of  the 
PELVIC  floor,  thus  enclosing  an  air  tight  cavity — the  true 
pelvic  cavity.  The  cavity  of  the  vagina,  which  is  formed  by 
separation  of  the  walls,  is  cone-shaped  with  the  base  above  and 
its  apex  at  the  hymen;  in  other  words,  the  cavity  is  shaped  like 
an  inverted  cone.  This  is  best  ascertained  by  admitting  air 
into  the  vagina  when  the  patient  is  in  the  knee-chest   position. 

"These  walls  are  composed  of  three  structures ; externally , 
a  fibrous  sheath,  internally,  a  mucous  membrane,  and  between , 
there  is  a  double  layer  of  muscles,  the  fibres  of  the  outer  being 
longitudinal,  the  inner,  circular."  The  posterior  wall  is  slightly 
longer  than  the  anterior,  being  about  three  and  a  half  inches  in 
length;  while  the  anterior  wall  is  about  two  and  a  half  inches. 
The  anterior  wall  is  intimately  blended  with  the  urethra  and 
trigone  of  the  bladder,  thus  any  displacement  of  this  wall 
such  as  occurs  in  cystocele,  interferes  with  the  function  of  the 
above  mentioned  organs. 

The  vagina  is  capable  of  great  distention,  with  power 
to  return  to  normal  without  loss  of  integrity.  On  transverse 
section  it  has  the  appearance  of  an  "H."  The  walls  are  covered 
with  mucous  membrane  which,  in  a  normal  subject  and  in  vir- 


ANATOMY. 


31 


gins,  and  especially  those  of  the  colored  race,  is  thrown  into  trans- 
verse folds  or  rugae.  These  rugae  aid  in 
promoting  sexual  excitement  and  con- 
tribute to  vaginal  enlargement  in  par- 
turition. Absence  of  these  rugae  is  in- 
dicative of  RELAXATION,  due  to  disease 
or  over-distention,  and  leads  to  pro- 
lapsus, not  only  of  the  vaginal  walls 
such  as  rectocele  and  cystocele,  but  of 
the  uterus.  Near  the  uterus,  the 
vaginal  walls  are  composed  principaljy 
of  contractile  and  erectile  tissues.  The 
healthier  the  vagina  is,  the  greater  the 
contractile  and  erectile  power,  and 
the  better  the  uterus  is  supported.  At 
the  lower  extremity  of  the  vagina  is  found 
a  thin  band  of  voluntary  muscle  called 
the  sphincter  vagina,  which  assists  in 
closing  the  lumen  of  vagina.  However, 
^  u  the  levator  ani  muscle  is  the  real  sphinc- 

FiG.  n-Aiiterior  wall  of   ^^r  of  the  vagina  since  by  its    contrac- 

vagina,   showing    columnae 

rugaruni    (Savage.)     ],    2,    tioii,  the  posterior  Wall  of  the  Vagina  is 

anterior  columns  of  the   va-       .    ,     ,       ,  •  ■, 

gina;  n,  ureteral  orifice:  m,  tightly  drawn  agauist  the  anterior.  Vari- 
*^^'^^'^'  ous   glands   are   here    located   which  se- 

crete an  acid  mucus,  which  acts  as  a  barrier  to  the  pass- 
ing of  micro-organisms  into  the  uterus.  Douches  frequently 
indulged  in  either  wash  away  or  neutralize  this  acid  mucus  and 
CAUSE  A  weakening  of  nature's  defenses  against  the  inroads  of 
disease.  Sometimes  this  secretion  is  increased  in  quantity  to 
such  an  extent  that  it  is  abnormal,  and  if  it  also  changes  in  quality 
it  is  called  leucorrhea. 


32 


DISEASES    OF    WOMEN. 


Ua 


The  vagina  has  a  triple  physiological  function.  During 
copulation  it  receives  the  penis;  during  parturition  it  acts  as  a 
protection  to  the  child  and  helps  move  it  along  the  curve  of 
Carus;  and  the  above  mentioned  power  of  the  normal  vaginal 
secretion  to  kill  bacteria,  and  thus  prevent  infection  of  the  in- 
ternal organs.  In  cases  in  which  there  is  a  weakness  of  the  mus- 
cles of  the  pelvic  floor,  the  va- 
ginal walls  tend  to  separate,  and 
on  account  of  this,  various  uterine 
displacements  are  likely  to  occur. 
Normally,  the  walls  fit  together 
so  accurately  that  during  copu- 
lation, or  the  making  of  a  local 
vaginal  examination  no  air  en- 
ters   THE    PELVIC    CAVITY,    UuleSS 

the  posterior  wall  is  drawn  con- 
siderably backward,  thus  bal- 
looning the  vagina. 

A  lesion  of  the  sacrum,  lower 
dorsal  and  lumbar  vertebrae,  es- 
pecially the  fifth  lumbar,  or  at 
sacro-iliac  synchondrosis  will 
affect  the  innervation  of  the  floor 

Fig.  12. — Horizontal  section  of  pel-  ,  ,  , 

vicfloor  near  pelvic  outlet.  Nhowinj;  AND      IT      SINKS      downward      and 

Taginai  and  rectal  slit.,  .ueuie )  Ua  backward,   thus   Separating    the 

urethra;  Va ,  vagina;  It  ,  rectum;  La  ,  i  c 

levator  ani.  l^^Q    vaginal    walls.     When    this 

occurs,  air  will  enter  the  cavity  which  is  normally  air-tight, 
and  this  destroys  the  equilibrium  of  the  pelvic  contents.  These 
points  are  of  special  interest  to  the  osteopath  in  the  treatment 
of  prolapsus  of  the  uterus,  and  are  anatomically  explained  by 
the  fact  that  the  above  mentioned  lesions  affect  the  pudic  and 


ANATOMY. 


33 


sacral  nerves  which  supply  the  pelvic  floor.     These    lesions    pro- 
duce   either   increased  tone    or    atony,  usually  the  latter. 

The.  arteries  come  from  the  anterior  division  of  the  internal 
iliac  or  one  of  its  branches,  which  include  the  vaginal,  uterine, 
middle  hemorrhoidal,  vesical  and  internal  pudic.  The  lower  part 
gets  the  middle  hemorrhoidal  and  internal  pudic,  the  middle 
part  the  vesical  and  the  upper  part,  the  cervico-vaginal  branches 
of  the  uterine.  The  veins  form  a  plexus  around  the  vagina  from 
which  spring  the  venae  comites  which  empty  into  the  pudic, 
thence  into  the  internal  iliac.  The  vaginal  veins  communicate 
with  those  draining  the  labia,  bulb,  bladder,  uterus  and  rectum, 
which  fact  furnishes  an  explanation  for  many  of  the  complica- 
tions of  uterine  and  rectal  vascular  disturbances.  The  lympha- 
tics, from  the  lower  third  of  the  the  vagina,  empty  into  the  in- 
guinal LYMPHATIC  glands;  those  from  the  middle  third,  into 
the  HYPOGASTRIC,  while  those  from  the  upper  third  empty  into 


Fis.  13.  Anterior  aspect  of  uterus, 
(Williams.) 


Fig  14. — Posterior  aspect  of  uterus, 
(Williams.) 


the  the  iliac  glands.     The  nerves  come  from  the  svmpathetic 

3 


34 


DISEASES    OF    WOMEN. 


vaginal  plexus,  most  of  which  terminate  in  end  bulbs.  A  prac- 
tical point  might  be  mentioned  here  in  regard  to  the  way  a  great 
many  people  sit.  Instead  of  sitting  on  the  tuber  ischii,  the 
WEIGHT  of  the  body  is  supported  by  the  sacrum,  and  this  inter- 
feres with  the  nerve  force  to  the  pelvic  organs  by  pressure  ex- 
erted on  the  PUDic  nerve  at  the  point  where  it  loops  around  the 
spine  of  the  ischium. 

THE  UTERUS.  The  uterus  is  a  pear-shaped  body  which 
is  located  in  the  true  pelvis,  with  the  larger 
end  upward.  It  is  bounded  anteriorly  and  in- 
f eriorly  by  the  bladder ;  superiorly  by  the  small 
intestines;  and  posteriorly  by  the  rectum. 
It  is  divided  into  two  parts,  the  .  body  or 
CORPUS  and  the  cervix  or  neck,  a  constric- 
tion corresponding  to  the  internal  os,  being 
the  line  of  division.  The  body  is  divided  into 
the  BODY  proper,  which  is  that  part  included 
between  the  cervix  and  entrance  of  the  Fal- 
lopian tubes,  and  the  fundus,  which  is  that 
part  located  above  the  entrance  of  the  Fallo- 
pian tubes. 

Fig  15. — Liiteral  view    '■ 

ot  uterus,  showing  It   IS   A   FREELY   MOVABLE     ORGAN,      being 

supra-vagiual  and   in-  .        .  . 

fra-vaginai  portions  anchored  by  elastic  ligaments.  It  is  moved 
m»nT''or'VeritoDeai  backward  when  the  bladder  is  filled  with 
covering  (Williams.)  yxYine  and  forward,  when  the  rectum  is  dis- 
tended. Its  LENGTH  varies,  the  average  being  about  three  and 
one-half  inches.  The  relation  between  the  length  of  the  body 
and  cervix    varies    greatly;    in    a  young  girl  the  body  is  only 

HALF  THE  LENGTH  OF  THE     CERVIX ;  in  YOUNG  VIRGINS  the  twO    are 

of  about  EQUAL  LENGTH  while  in  MULTiPAROus  WOMEN  the  cer- 
vix is  little   more    than  one-third  of     the    total  length  of  the 


ANATOMY. 


35 


uterus.  The  parous  uterus  is  from  a  third  to  half  larger  than 
the  virgin  uterus.  After  the  menopause  all  the  dimensions  are 
decreased. 

The  portion  of  the  cervix  which  extends  into  the  vagina  is 
called  the  infra-vaginal  portion,  and  that  part  above  the 
junction  of  the  vagina  and  the  uterus,  is  called  the  supra-vaginal 
portion.     The    infra-vaginal    portion  extends  about  an  inch  into 

the  upper  part  of  the  vagina 
and  can  be  encircled  by  the  ex- 
amining finger.  This  space  or 
cavity  around  the  cervix  has 
been  divided  for  convenience, 
into  the  anterior,  lateral,  and 
posterior  fornices  of  the  vagina. 
Fig.  16  illustrates  the  relation 
of  the  uterus  to  the  vagina 
and    the    location     of    the   for- 


Fig.  16 — Showing    junction   of    vagina 
and  cervix. 


nices. 


The  lower  portion  of  the  cervix  is  circular  like  a  rounded 
cone  and  should  feel  smooth  and  of  about  the  consistency  of 
the  end  of  the   nose.     It    is  pierced  in  the   center  by  an   open- 


Fm.  17. — Virginal  exter- 
nal OA. —  (Williams  ) 


-i'.UMUs  t-AU-iUal 

-  (Williams.) 


ING,  felt  as  a  dimple  in  nullipara,  as  a  transverse  slit  in  multi- 


36 


DISEASES   OF   WOMEN. 


para,  which  is  the  os  externum.  The  external  os  varies  greatly 
as  to  size  and  appearance.  In  the  virgin  it  is  small  and  oval- 
shaped  resembling  a  tench's  mouth,  hence  the  name  os  tincae. 
After  labor  it  becomes  converted  into  a  transverse  slit  with 
changes  that  are  so  characteristic,  that  one  can  determine  with 
a  fair  degree  of  accuracy  whether  the  woman  has  ever  been 
pregnant.  If  this  slit  were  extended,  it  would  divide  the  cer- 
vix into  an  anterior  and  a  posterior 
lip;  the  posterior  appearing  to  be 
longer  on  account  of  the  posterior 
fornix  being  deeper  than  the  an- 
terior. Normally  the  cervix  is 
HARD,  it  being  composed,  in  part, 
of  connective  tissue  in  which  are 
found  many  non-striated  muscle 
fibers  which  are  circular;  also 
ELASTIC  tissue  is  present,  this  per- 
mitting of  GREAT  DISTENTION.  If 
it  is  found  to  be  soft,  it  indicates 

FiG.iy-Recon.tTiTction     of  uterus  a     DISEASED     CONDITION      OR     PREG- 

8howing  shape  of  uterine  cavit J  and  ^^j^^Y.  In  Conditions  of  SUMu- 
cervical  canal.  (\\  illianis.) 

volution  the  os  is  usually  patulous.  In  cases  in  which  the 
cervix  is  lacerated,  it  is  irregular  with  roughened  elevations 
which  are  the  result  of  inflammation  of  the  Nabothian  glands. 
These  glands  undergo  a  caseous  or  cystic  degeneration  and 
when  this  takes  place,  the  name  Nabothian  cysts  is  given 
them.     They  feel  like  shot  imbedded  in  the  cervix. 

During  infancy  and  in  the  infantile  types  of  uteri,  the  cer- 
vix constitutes  as  stated  before,  the  larger  part  of  the  uterus, 
and  is  situated  very  high  in  the  pelvis.  After  the  menopause 
the  cervix  undergoes  a  fibrous     degeneration,   it  feeling  like  a 


ANATOMY.  37 

cartilaginous  ring,  and  becomes  so  shortened  that  in  many  cases,  the 


Fig.  20— Sagittal  section  through  body  of  newly  born  child.     (Williams.) 

vagina  finally  terminates  in    the  os  uteri  without    any  palpable 
projection  of  the  cervical  portion  into  the  vagina. 

The  body  is  triangular  in  appearance  and  has  three  open- 
ings; one  below,  the  os  of  the  uterus;  and  two  above,  one  at  eithe 
comer  formed  by  the  entrance  of  the  Fallopian  tubes.  It  is 
flattened  antero-posteriorh^ ;  the  anterior  and  posterior  surfaces 
being  free,  while  the  broad  ligaments  obscure  the  outline  of  the 
edges.  The  Fallopian  tubes  are  attached  to  each  upper  comer 
of  the  uterus;  immediately  below  them  is  the  attachment  of  the 
ROUND  LIGAMENTS  and  just  beneath  the  round  ligaments  the 
insertion  of  the  ovarian  ligaments. 

The  CAVITY  of  the  uterus  is  small  in  comparison  to  its  size. 


38 


DISEASES    OF    WOMEN. 


Its   length   is    about    two  and  a  half  inches.     It  is  triangular 


Fig.  21 — Sagittal  section  through  aflult  woman  (  Kcllcy)  reduced  to  same   size  as 
Fig.  20  for  conii)aris()ii.     (Williams.) 

in  shape  and  connects  with  the  various  openings.  At  the 
junction  of  the  cervix  and  body  is  a  slight  constriction 
which  corresponds  to  the  inteiiial  os.  The  endometrium  of  this 
part  and  that  of  the  cervix  is  so  arranged  that  it  has  the  ap- 
pearance of  an  ARBOR  viT^.  These  palm^  plicate  consist 
of  two  ridges  which  run  along  the  median  line  of  the  anterior  and 
posterior  walls  respectively  and  give  off  numerous  lateral 
branches.  It  is  a  curious  coincidence  that  there  is  this  branch- 
like arrangement  of  the  tissues  in  the  womb,  and  that  a  some- 
what similar  arrangement  exists  in  the  cerebellum,  the  predom- 
inate, central  organ  of  the  sexual  instinct. 

The  mucous  membrane  lining  the  cavity  of  the  uterus  is 


ANATOMY. 


39 


called  endometrium.     It    is  a  soft,  thin,  pinkish  membrane  which 
is  very  intimately   connected  with  the  muscle  fibers  forming  the 


Fig.  22. — Fetal  uterus  and  va- 
gina (Byford  from  Winkel.)  o.  In- 
ternal os;  V.  1  anterior  lip;  h.  1. 
postenor  lip. 


Fig.  23.— Infantile  uterus, 
from  Wlnkel.) 


(By  ford 


uterine  wall.  In  fact,  it  is  so  thin  and  so  tightly  and  securely 
attached  that  it  is  practically  impossible  to  dissect  it  out.  In 
curettage,  in  which  a  sharp  instrument  is  used,  it  is  partly  re- 
moved and  with  it  portions  of  the  uterine  wall  on  account  of  the 
above  mentioned  facts.  This  membrane  is  perforated  by  ducts 
of  the  numerous  uterine  glands.  These  glands  secrete  a  thin 
ALKALINE  FLUID,  the  function  of  which  is,  to  lubricate  the  lining, 
to  keep  the  cavity  moist,  and  to  protect  against  the  invasion  of 
micro-organisms.  In  normal  cases  cilia  are  present.  The  current, 
produced  by  their  action,  according  to  Hofmeir,  is  now  proven 
to  be  from  above  downward  instead  of  from  below  upward  as 
was  once  believed. 

The  walls  are  composed  of  three  layers;  the  serous  or  peri- 
toneal, muscular  and  a  mucous  coat.  The  muscular  coat  is  also 
divided   into   three  layers;  longitudinal,   circular   and   oblique. 


40  DISEASES   OF    WOMEN. 

The  LONGITUDINAL  FIBERS  predominate  in  the  fundus  and  re- 
ceive their  nerve  supply  principally  from  the  sympathetic 
nervous  svstem,  while  the  circular  fibers  predominate  in  the  cer- 
vix and  are  supplied  almost  entirely  by  cerebro-spinal  nerves. 
These  two  sets  of  muscle  fibers  are  opposite  in  their  action,  that 
is,  when  the  fundus  contracts  the  cervix  relaxes,  and  when  cer- 
vix contracts  the  fundus  relaxes.  This  is  called  polarity  and 
upon  it  depends,  normal  menstruation  and  parturition.  The 
OBLIQUE  layer  is  arranged  like  the  figure  eight  and  the  fibers, 
winding  around  the  blood  vessels,  thus  form  a  ligature  of  them 
during  contraction  of  the  uterus. 

If  the  AXES  of  the  uterus  and  the  vagina  were  extended,  they 
would,  in  a  theoretically  perfect  case,  meet  at  right  angles;  how- 
ever, this  varies  according  to  the  distention  of  the  bladder  and 
rectum.  In  the  genu-pectoral  position  the  uterus,  if  in  a  nor- 
mal position,  will  be  in  a  perpendicular  line,  the  heavy  end  or 
fundus  down.  In  treating  the  various  displacements,  especially 
retro-deviations,  advantage  is  taken  of  this,  since  the  uterus, 
when  the  patient  is  in  this  position,  like  a  pendulum  tends  to 
swing  toward  the  perpendicular  line,  which  is  the  normal  posi- 
tion, unless  held  out  of  position  by  adhesions.  In  a  nulliparous 
patient  this  treatment  is  first  used  if  a  displacement  of  the  uterus 
exists,  which,  if  coupled  with  a  "lifting  up"  manipulation  of  the 
prolapsed  bowels,  is  successful  in  most  cases. 

The  CERVIX  is  regarded  by  some  as  a  large  mucous  gland; 
injury  or  disease  of  which  produces  an  abnormal  secretion  or 
leucorrheq. 

The  blood  supply  of  the  uterus  is  from  two  sources,  the  uterine 
and  ovarian  arteries.  The  uterine  comes  from  the  anterior 
division  of  the  internal  iliac,  and  after  descending  for  a  short 
distance  enters  the  base  of  the  broad  ligaments,   crosses   the 


ANATOMY.  41 

ureter  and  reaches  the  side  of  the  uterus.  It  divides  just  before 
reaching  the  supravaginal  portion  of  the  cervix  into  two  branches: 
the  SMALLER,  or  cervico-vaginal,  supplies  the  lower  portion  of 
the  cervix  and  upper  part  of  the  vagina:  the  larger  becomes 
markedly  convoluted  and  extends  along  the  margin  of  the  uterus 
and  gives  off  numerous  branches  which  penetrate  into  its  sub- 
stance. It  finally  divides  into  three  terminal  arteries :  the  ovariar, 
the  tubal  and  one  going  to  the  fundus;  the  names  indicating 
their  destination.  Pulsation  can  be  readily  felt  in  these  arteries 
when  they  are  congested,  especially  if  there  is  metritis. 

The  OVARIAN  is  from  the  abdominal  aorta.  It  enters  the 
broad  ligament  near  the  origin  of  the  infundibulo-pelvic  liga- 
ment and  from  this  part  numerous  branches  go  to  the  ovary. 
The  main  stem  traverses  the  entire  length  of  the  ligament  and 
supplies  the  fundus  of  the  uterus,  there  anastomosing  with  the 
ovarian    branch  of    the    uterine.     All    tfie    arteries   in  the 

UTERUS  FREELY  ANASTOMOSE. 

The  VEINS  are  formed  into  plexuses  around  each  artery.  The 
blood  from  the  lower  part  reaches  the  internal  iliac  vein;  that 
from  the  ovary  and  upper  part  of  the  uterus  and  Ijroad  ligaments 
is  collected  by  a  great  number  of  veins  which  go  to  form  a  large 
plexus,  which  on  account  of  its  supposed  resemblance  to  a  ten- 
dril is  called  the  pampiniform  plexus  of  veins.  The  ovarian  vein 
drains  this  plexus.  The  right  ovarian  terminates  in  the  inferior 
vena  cava,  the  left  in  the  renal;  the  former  at  an  acute  angle,  the 
latter  at  about  a  right  angle. 

The  lymphatic  vessels  of  the  lower  part  of  the  uterus  termi- 
nate in  the  hypogastric  glands,  which  are  situated  between  the 
hypogastric    and   external    iliac    arteries.     The   lumbar   glands 
drain  the  remaining  part  of  the  uterus. 

The  nerve  supply  is  from  two   sources,  cerebro-spinal    and 


42 


DISEASES    OF    WOMEN. 


sympathetic.  The  anterior  divisions  of  the  second,  third  and 
fourth  sacral  nerves  largely  supply  the  circular  muscle  fibers  of 
the  cervix.  The  body  is  supplied  almost  entirely  by  the  uterine 
and  ovarian  plexuses;  the  uterine  being  derived  from  the  pelvic 
or  inferior  hypogastric  plexus  and  sacral  nerves  and  the  ovarian 
from  the  renal  and  aortic  plexuses.  Some  authors  speak  of  a 
large  cervical  nerve  ganglion,  which  lies  to  the  side  of,  and  be- 
hind the  cervix. 

LIGAMENTS   OF  THE   UTERUS.     The   ligaments   of   the 
uterus  are  eight  in  number,  two  broad,  two  sacro-uterine, 


UTERO-SACRAL  LIG'T. 


URETER 


OVARY 
APPENDIX 


UTERUS 


MBRIAOF 
FALLOPIAN  TUaE 


BROAD  LIGT. 

UTERO-VESICAL  LIG'T. 


BLADDER 


URACHUS 


INSERTION  OF  ROUND  LIGT. 
Fig.  24 — Superior  view  of  pelvic  viscera. 

two  ROUND,  VESICO-,  and  recto-uterine,  which  serve  to  anchor, 
rather  than  support,  the  uterus.     Six  of  them  are  composed  of 


ANATOMY.  43 

folds  of  the  peritoneum,  the  remaining  two,  the  round  ligaments, 
are  musculo-fibrous  in  structure. 

All  of  them  are  more  or  less  contractile  and  elastic,  and 
by  osteopathic  treatment  these  properties  can  be  increased  or 
decreased.  In  the  treatment  of  the  various  uterine  displace- 
ments, but  partif'ularly  prolapsus,  it  is  the  aim  of  the  physician 
to  restore  tone  to  these  ligaments,  in  fact,  this  must  be  accom- 
plished before  a  cure  can  be  effected. 

The  vesico-uterine  ligament  is  a  fold  of  peritoneum  which 
is  attached,  anteriorly  to  the  bladder  and  posteriorly,  to  the 
supra-vaginal  portion  of  the  cervix  and  lower  part  of  the  corpus. 
Some  authors  speak  of  this  fold  of  the  peritoneum  as  an  ad- 
hesion, which  term  describes  it  more  accurately  than  does  the 
term  ligament.  Its  function  is  to  hold  the  lower  part  of  the 
uterus  in  position,  that  is  to  hold  the  uterus  in  relation  with  the 
bladder.  Its  action  is  counteracted  by  that  of  the  sacro-uterine 
ligament.  The  two  sacro-uterine  ligaments  suspend  the  uterus 
in  the  pelvic  cavity  and  with  the  vesico-uterine  form  an  axis 
or  fixed  point,  around  which  nearly  all  the  uterine  movements 
take  place.  In  distention  of  the  bladder  the  body  of  the  uterus 
is  forced  backward  and  the  cervix  moves  forward.  The  reverse 
is  true  in  impaction  of  the  rectum.  The  uterus  cannot  descend 
unless  the  utero-sacral  ligaments  relax;  it  cannot  rise  without 
relaxation  of  the  anterior  or  vesico-uterine  ligament. 

One  cannot  better  ascertain  the  nature,  direction  and  ex- 
tent of  these  movements  than  by  provoking  them  by  means  of 
the  finger  in  the  vagina,  by  which  pressure  is  exerted  on  cervix. 
In  pushing  the  cervix  backward  the  fundus  moves  forward;  in 
pulling  it  forward  the  fundus  goes  backward ;  in  pushing  or  pulling 
it  to  the  right,  the  fundus  is  rotated  to  the  left,  and  vice  versa. 
In  short,  the  fundus,  in  a  normal  case,  is  always  in  an  opposite 


44  DISEASES    OF    WOMEN. 

direction  to  that  of  the  cervix  and  is  freely  moved  by  the  above 
methods.  In  inflammatory  conditions  of  the  vesico-uterine  lig- 
ament, such  as  occur  in  local  peritonitis  complicating,  or  follow- 
ing metritis,  adhesions  are  likely  to  be  formed  which  bind  the 
uterus  to  the  bladder.  As  a  result  of  this  the  bladder  is  irritated. 
At  first  there  is  frequent  micturition  followed  by,  in  pronounced 
cases,  a  sort  of  spasm  or  tenesmus  immediately  after  the  com- 
pletion of  the  act. 

SACRO-UTERINE  LIGAMENTS.  The  sacro-uterine  liga- 
ments are  two  folds  of  peritoneum  which  are  attached  to  the 
anterior  surface  of  the  second  sacral,  sometimes  the  first,  or  as 
high  as  the  fifth  lumbar  vertebra,  and  to  the  posterior  surface 
of  the  uterus  on  a  level  with  the  os  internum.  When  the  patient 
is  in  the  erect  posture  they  are  nearly  vertical,  which  position 
very  materially  assists  in  supporting  the  uterus.  They  are  known 
as  the  folds  of  Douglas  and  constitute  the  upper  lateral  boundary 
of  the  pouch  of  Douglas  and  are  the  most  important  of  all  the 
ligaments.  They  contain  contractile  fibers  and  are  called  the  re- 
tractor muscles  of  the  uterus.  Deaver  describes  them  as  flat 
muscular  bands  which  extend  from  the  uterus  at  the  level  of  the 
internal  os,  beneath  the  layers  of  the  recto-uterine  ligament,  to 
the  sides  of  the  sacrum  opposite  the  lower  border  of  the  sacro- 
iliac articulation.  Between  the  two  ligaments  passes  the  rectum, 
as  shown  in  Fig.  25.  In  distended  conditions  of  the  rectum 
these  ligaments  are  affected,  that  is,  they  are  irritated  and  tend 
to  retract  the  uterus.  These  ligaments,  working  in  conjunc- 
tion with  the  round  ligaments,  hold  the  uterus  in  anteversion, 
and  if  both  are  shortened,  anteflexion  will  result.  Also  the 
ligaments  prevent  the  uterus  from  being  pulled  down  very  far, 
and  if  there  is  a  condition  of  prolapsus,  the  traction  exerted  upon 
them  by  the  weight  of  the  uterus,  will  result  in  an  irritation  of 


ANATOMY. 


45 


the  nerves  which  make  their  exit  at  the  first,  second  and  third 
sacral  foramina,  hence  the  backache  which  usually  accompanies 
such  conditions.     These  ligaments  play  a  very  important  role 


Fkj  2"). — The  ut»»ro-8iicr!il  ligaments:  showing  relation 
to  rectum — (After  Test  lit). 

in  uterine  displacements.  If  they  retain  their  normal  muscular 
tone  and  contractile  power,  the  uterus  can  with  difficulty  be  dis- 
placed. 

The  NERVE  supply  of  these  ligaments  is  very  great  on  ac- 
count of  their  structure,  they  being  composed  of  peritoneum 
and  muscle  fibers.  It  comes  principally  from  the  third  and  fourth 
sacral  nerves.     Since  these  nerves  also  supply  the  pelvic  floor 


46  DISEASES    OF   WOMEN. 

and  uterus,  a  disease  of  one  part  will  affect  the  other.  A  lesion 
affecting  one  will  in  time  affect  all.  A  relaxed  vagina  means  a 
relaxed  condition  of  the  sacro-uterine  ligaments  and  thus  furnishes 
an  almost  infallible  sign  as  to  the  condition  of  the  uterus. 

THE  RECTO-UTERINE  LIGAMENT.  The  recto- 
uterine ligament  is  a  fold  of  peritoneum  which  connects  the 
rectum  with  the  lower  part  of  the  uterus  and  is  really  a  part  of 
the  sacro-uterine  ligaments,  it  being  enclosed  by  them.  This 
fold  of  peritoneum  which  is  placed  between  the  rectum  and 
uterus  also  helps  to  form  the  pouch  of  Douglas.  Adhesions 
sometimes  exist  between  the  two  layers  of  peritoneum  forming 
the  walls  of  the  cavity,  thus  obliterating  it  and  fixing  the  uterus 
to  the  rectum. 

BROAD  LIGAMENTS.  The  broad  ligaments,  sometimes 
called  the  pelvic  diaphragm  because  they  divide  the  pelvic  cav- 
ity into  two  parts  and  move  synchronously  with  respiration,  are 
TWO  lateral  parts  of  the  double  peritoneal  folds,  which  con- 
tinue from  the  bladder  over  the  uterus  to  be  reflected  on  the 
rectum,  and  contain  within  their  folds  the  uterus  and  its  append- 
ages, the  ovaries  and  their  ligaments.  Fallopian  tubes,  arteries, 
veins,  lymphatics  and  nerves  supplying  the  uterus,  the  paro- 
varium and  the  round  ligaments. 

They  resemble,  in  shape,  the  outstretched  wings  of  a  bat 
and  are  attached  to  the  edge  of  the  uterus  and  to  the  pelvic 
WALL.  Their  attachment  to  the  pelvic  wall  corresponds  to  "a 
line  extending  from  a  point  midway  between  the  sacro-iliac  artic- 
ulation and  the  ilio-pectineal  eminence,  downward  and  back- 
ward between  the  great  sacro-sciatic  notch  and  the  obturator 
foramen  to  the  level  of  the  spine  of  the  ischium."  Thus  a  partial 
dislocation  of  the  innominate  bones  will,  in  some  way,  affect  this 
end  of  the  broad  ligament.     The   upper  surfaces  are  free,  while 


ANATOMY. 


47 


the  other  parts    are  attached  to  adjacent  structures  and  vis- 
cera and  are  continuous  wath  the  pelvic  peritoneum. 

They  are  not  formed  entirely  of  peritoneum  but  are  lined 
throughout  their  whole  extent  with  a  layer  of  muscle  fibers.  Their 
FUNCTION  is  to  prevent  lateral  displacements,  or  in  fact,  any 
other  displacement  resulting  from  a  change  of  posture  of  the 
body.  When  they  are  severed  in  the  dead  body,  the  uterus, 
obeying  the  laws  of  gravity,  inclines  to  the  side  on  which  the  bod  ' 
is  lying,  W'hile  it  reassumes  its  position  when  the  ligaments  are 
sutured. 


Fig.  26 — View  of  pelvic  organs  seen  from  above  (Savage).  \i.  Rectum, 
O.  Ovary.  F.  Fallopian  tube,  F.  Fimbriae,  L.  Kouml  ligament,  U.  Uterus, 
B.  Bladder,  V.  Vertebra,  M.  Pubic  fat,  b.  Broad  ligament,  g.  Ureter. 

Between  these  two  layers  is  located  a  pampiniform  plexus 
of  veins  which  drains  the  ovaries  and  uterus.     From  the  fact 
that  the  broad  ligaments  are  attached  to  the  edges  of  the  uterus 
any   forward   or   backward   displacement    will   necessarily  twist 
these  ligaments  and  compression  of  the  vessels  in  the  broad  lig- 


4b  diseases  of  women. 

aments  varying  with  the  amount  of  displacement,  results.  Press- 
ure on  the  veins  forming  the  above  mentioned  plexus,  produces 
a  condition  analogous  to  varicocele  in  the  male.  This  condi- 
tion is  hard  to  diagnose  during  life,  but  a  thickened,  lumpy, 
tortuous  condition  of  the  broad  ligaments  is  symptomatic  of  this 
disease,  especially  if  there  is  a  dull,  constant  ache  in  the  re- 
gion of  this  plexus.  This  congested  condition  also  follows  or 
accompanies  ungratified  sexual  desire,  and  is  most  to  blame 
for  the  heavy  dead  ache  ivnariably  referred  to  the  ovary,  in  such 
cases.  As  a  result  of  this  varicose  condition ,  the  ovary  atrophies 
or  degenerates ;  the  fibro-cystic  form  of  degeneration  being  most 
common. 

In  congestion  of  the  uterus  following  displacement,  the 
uterus,  if  possible,  should  be  held  in  normal  position  for  a  few 
minutes  in  order  that  these  ligaments  may  become  untwisted  and 
the  engorgement  of  the  blood  be  relieved.  This  can  be  done 
digitally  or  better  by  the  "Old  Doctor's"  uterine  repositor. 

Inflammation  of  these  ligaments  results  in  ovarian  or  Fal- 
lopian tube  disease,  and  in  lateral  displacement  of  the  uterus, 
as  a  result  of  their  shortening,  which  is  the  usual  effect  of  in- 
flammation. A  great  many  reflex  troubles  depending  upon 
uterine  disease,  result  from  a  twisting  or  straining  of  these  lig- 
aments, that  is,  the  displacement  in  itself  does  not  cause  very 

MUCH  trouble  unless  IT  AFFECTS  THE  NERVES  and  BLOOD  VES- 
SELS which  are  enclosed  between  the  two  layers  of  these  ligaments. 
A  great  deal  of  the  tenderness  of  the  abdomen  which  accompanies 
uterine  disease,  is  due  to  a  thickening  and  congestion  of  these 
ligaments,  and  by  replacing  the  uterus  the  soreness  will  usually 
disappear  within  a  short  time.  In  congestion  or  inflammation 
of  these  ligaments  the  patient  complains  of  a  drawing  sensation 
in  the  side.     On  palpation  in  such  conditions  the  ligaments  can 


ANATOMY.  49 

easily  be  palpated.  I  make  it  a  routine  practice  to  closely  ex- 
amine these  ligaments  when  uterine  trouble  exists,  since  the 
cause  or  effect  is  commonly  found  in  them.  In  many  cases  this 
TIGHTENING  or  DRAWING  SENSATION  is  entirely  due  to  a  con- 
traction of  this  ligament;  which  condition  follows  strains,  mus- 
cular, bony  and  visceral  lesions.  Reaching  up,  as  in  overhead 
work,  is  responsible  for  man\^  cases. 

ROUND  LIGAMENTS.  The  round  Ugaments,  two  in  num- 
ber, are  attached  to  the  upper  corners  of  the  uterus  just  in 
front  of  and  below  the  entrance  of  the  Fallopian  tubes,  and  ter- 
minate in  the  mons  Veneris,  symphisis  pubis,  and  labia  majora. 
Their  course,  describing  a  curve,  is  first  upward  and  outward, 
then  downward  and  forward  outside  the  bladder  to  the  internal 
abdominal  ring  and  then  through  the  inguinal  canal,  over  the 
pubic  bone,  at  which  place  they  terminate  in  the  above  men- 
tioned structures.  They  are  composed  of  fibrous  tissue  and 
MUSCLE  fibers  wMch  are  continuous  with  the  muscle  fibers 
OF  THE  uterus,  AND  ARE  CONTRACTILE.  They  receive  addi- 
tional muscle  fibers,  while  in  the  inguinal  canal,  which  muscle 
fibers  correspond  to  the  cremaster  muscle  in  the  male.  These 
ligaments  give  off  muscular  branches  which  strengthen  the  ex- 
ternal ABDOMINAL  ring. 

An  artery,  the  funicular,  a  branch  of  the  superior  vesical, 
a  plexus  of  veins  and  the  genital  branch  of  the  genito-crural 
nerve,  are  contained  in,  or  accompany  the  ligament. 

In  diseased  conditions  of  the  uterus  which  cause  a  weaken- 
ing of  its  walls,  the  effect  extends  to  the  round  ligaments,  causing 
their  relaxation.  During  fetal  life  the  peritoneum  accompanies 
the  round  ligaments,  forming  a  pouch  called  the  canal  of  Nuck, 
which  corresponds  to  the  processus  vaginalis  of  the  male,  but 
usually  becomes  obliterated  at  birth.     Sometimes  it  is  persist- 

4 


60 


DISEASES    OF    WOMEN. 


ent,  and  congenital  female  hydrocele  results.  During  pregnancy 
the  round  ligaments  become  very  large  and  vascular.  The 
stretching  of  these  ligaments  during  pregnancy,  as  a  result  of 
the  enlargement  and  ascent  of  the  gravid  uterus,  is  productive 


Fig.  27. — The  pelvic  viscera  of  a  woman  neen   from  above,   (the  left 
ovary  and  tubeliave  been  drawn  up  into  the  left  iliac  fo.ssa)  (Testut) 

of  more  or  less  pain  or  discomfort  in  the  iliac  fossae.  Their 
FUNCTION  is  to  hold  the  uterus  in  anteversion  and  prevent  retro- 
displacements  resulting  from  coughing  or  straining  at  stool.     In 


ANATOMY. 


51 


cases  of  weakness  of  the  uterus,  these  ligaments  lose  their  tone 
and  the  tendency  to  retro-displacement  increases  upon  any  in- 
crease of  intra-abdominal  pressure.  This  function  is  artifici- 
ally restored,  or  at  least  is  supposed  to  be  restored,  by  Alex- 
ander's operation,  which  consists  of  a  shortening  of  the  round 
ligaments.  Hernia  has  followed  this  operation  as  a  result  of 
the  weakening  of  the  abdominal  wall  at  the  point  of  exit  of  the 
ligament   at    which  place  the  incision  is  made. 

FALLOPIAN  TUBES.  The  Fallopian  tubes,  named  after 
their  discoverer  Fallopius,  are  two  tubes  about  the  size  of  slate 
pencils,  which  connect  the  ovaries  with  the  uterus.  They  are 
from  three  to  five  inches  in  length.  The  tubes  have  their  origin 
in  each  comer  of  the  uterus,  going  first  outward,  then  turn  back- 
ward, finally  curving  round  the  free  end  of    the   ovaries,  some- 


limbriated 
extremity. 


Iki';., 

Ill  h    I 


Fimbria  ■-'.■.  ,  .      .   >•*/ 

warxca.  '^  '^  •-' 

KiG   28. — Tlie  FalU)i)lan  tube  .'uid  ovary  Bf-en   from  behind.  (Heiile) 

times  entirely  surrounding  them.  They  have  three  coats;  ser- 
ous, muscular  and  mucous.  Upon  the  mucous  coat  is  found 
ciliated  epithelium   which  helps  to  convey  the  ova  to  the  uterus. 


52  •  DISEASES    OF   WOMEN, 

The  tubes  are  divided  into  three  parts;  the  isthmus,  ampulla 
and  fimbriae.  The  isthmus,  or  part  attached  to  the  uterus,  is 
the  smallest  part;  the  opening  of  the  ostium  internum  is  so  fine 
that  it  barely  admits  a  bristle.  The  ampulla  is  the  middle  part 
and  is  called  the  receptacle  of  the  semen,  because  impregnation 
is  supposed  to  take  place  at  this  point.  The  ovarian  end  of  the 
tube,  at  which  end  is  found  the  ostium  abdominale,  is  surrounded 
by  fimbriae,  they  giving  it  the  appearance  of  having  tentacles. 
One  of  these  called  the  fimbria  ovariana,  anchors  the  tube  to 
the  ovary  and  facilitates  the  passage  of  the  ovum  to  the  tube. 
Some  authors  say  that  these  fimbriae  are  erectile,  and,  during 
the  escape  of  the  ovum,  surround  the  ovary.  The  function  of 
the  tube  is  to  transmit  the  ova  to  the  uterus  and  to  serve  as  a 
receptacle  for  the  spermatozoa.  The  ova  arc  transmitted  by 
suction,  the  action  of  the  ciliated  epithelium  and  by  peristalsis. 
The  TIME  required  for  an  ovum  to  reach  the  uterus  has  been  es- 
timated to  be  from  five  to  ten  days.  I  have  had  patients  tell 
me  that  they  could  tell  when  the  ovum  was  expelled;  it  usually 
being  about  two  days  after  the  cessation  of  the  menstrual  flow. 
From  a  few  experiments,  I  have  found  that  in  some  cases,  a  small 
gelatinous  mass  is  expelled  within  three  days  after  menstruation, 
this  being  the  ovum  and  its  attachments,  and  that  impregnation 
does  not  occur  after  its  expulsion. 

In  diseased  conditions  of  the  tubes,  its  function  is  disturbed, 
that  is,  the  ova  are  not  transmitted  to  the  uterus,  or  at  least  very 
slowly  if  at  all,  hence  sterility  or  tubal  pregnancy.  Probably 
a  great  number  of  ova  fall  into  the  abdominal  cavity  and  there 
dry  up;  although  in  some  instances  a  spermatozoon  finds  its 
way  there,  it  being  self-mobile,  and  abdominal  pregnancy  is  the 
result. 

Fluids,  when  forced  into  the  uterine  cavity  ,find  their  way 


ANATOMY. 


53 


into  the  abdominal  cavjty  by  way  of  the  tubes.  This  is  especi- 
ally true  if  intra-uterine  douches  are  used  in  post-partum  cases. 
It  is  also  the  case  in  some  instances  in  which  the  tubes  are  en- 
larged. Cases  of  peritonitis  are  on  record  which  followed  an  in- 
jection of  bi-cloride  of  mercury  solution  into  the  uterine  cavity; 
some  of  the  fluid  passing  into  the  abdominal  cavity  by  way  of 
the  tubes  and  being  absorbed  by  the  peritoneum,  produced  a 
poisoning. 

In  CONGESTION  of  the  tubes,  they  can  be  outlined  by  ex- 
ternal palpation.  They  are  felt  as  tender,  cord  like  bodies  ex- 
tending outward  from  the  edges  of  the  uterus. 

THE  OVARIES.     The  ovaries  are  two  almond  shaped  bodies 


Fig.  29. — Ovary  at  the  age  of  twenty.      (From  Seliultze) 

varying  in  size   in  different  people  and  at  different  times  in  the 
same  individual,  which  are  attached  to  the  posterior  layer  of 


54  DISEASES    OF    WOMEN. 

the  broad  ligaments,  uterus  and  pelvic  wall.  They  are  about  one 
and  one-half  inches  long,  about  three  quarters  of  an  inch  wide, 
and  one-half  an  inch  thick;  and  are  located  within  an  inch  to  an 
inch  and  a  half  of  the  uterus.  They  are  so  near,  and  so  securely 
attached  to  the  uterus,   that   every   uterine    displacement 

WOULD   PRODUCE  AN   OVARIAN   DISPLACEMENT. 

The  OVARIES  are  regarded  as  the  most  important  of  all  the 
pelvic  viscera.  Without  them  there  would  be  no  menstruation, 
poor  development  of  the  uterus  and  the  mammary  glands,  and 
in  fact,  the  other  pelvic  organs  would  practically  be  useless. 

They  are  held  in  position  by  the  broad,  the  infundibulo- 
pelvic  ligaments,  which  attach  them  to  the  pelvic  walls,  and  the 
ovarian  ligaments,  which  anchor  them  to  the  uterus.  Although 
apparently  securely  attached,  their  mobility  is  quite  marked, 
and  DISPLACEMENT  is  one  of  the  most  frequent  of  its  lesions. 

The  iNFUNDiBULO-PELVic  LIGAMENT  is  that  part  of  the  upper 
margin  of  the  broad  ligament  in  relation  with  the  Fallopian  tube. 
The  OVARIAN,  is  a  longitudinal  fold  of  the  peritoneum  into  which 
unstriped  muscle  fibers  from  the  uterus  are  prolonged. 

During  early  fetal  life  they  are  found  in  the  abdominal  cav- 
ity. Descent  is  not  complete  until  about  the  tenth  year.  They 
remain  quite  small  and  undeveloped  up  to  puberty,  at  which 

TIME  THEY  ASSUME  THE  APPEARANCE  OF  AN  ADULT  OVARY. 

The  EXTERNAL  LANDMARKS  are  the  anterior  superior  spines 
of  the  iliac  bones;  the  ovaries  being  located  about  two  inches 
internal  and  one  and  one-half  inches  inferior  to  this  spine.  The 
SIZE  varies  according  to  the  age  of  the  individual,  and  according 
to  the  state  of  sexual  activity.  After  cessation  of  sexual  life 
the  ovaries  atrophy,  diminishing  in  size  from  one-half  to  one- 
third.  In  old  women  they  are  often  as  small  as  peas,  the  atrophy 
being  gradual  after  the  menopause.      During  pregnancy,  how- 


ANATOMY. 


55 


ever,  they  are  doubled  in  size. 

They  consist  of  two  parts,  the  stroma  or  framework  and  the 
PARENCHYMA.  They  are  covered  by  columnar  epithelium,  some- 
times   called   germinal    epithelium.     Immediately    beneath    this 


Fig.  30.— Ovary  at  the  age  of  forty.     (From  Schultze) 

epithelial  layer,  is  the  tunica  albuginea  which  is  composed  of 
fibrous  tissue  which  contains  a  few  muscle  fibers. 

The  Graafian  follicles,  in  all  stages  of  development,  are  em- 
bedded in  the  connective  tissue  or  stroma  and  contain  the  ova. 
The  younger  and  smaller  lie  in  the  cortical  area.  Their  number 
is  immense,  it  being  estimated  from  40,000  to  70,000.  During 
menstruation  one  or  more  of  these  follicles  ruptures,  permitting 
the  ovum  to  escape.  After  rupture  it  is  caught  by  the  fimbriated 
extremity  of  the  tube,  carried  into  the  tube  and  transmitted  to 
the  uterus,  partly  by  action  of  the  ciliae  and  partly  by  peristalsis. 

In  young  women  the  ovary  is  smooth  and  glistening  in  ap- 
pearance; but  as  the  woman  continues  to  menstruate,  and  the 
Graafian  follicles  rupture,it  begins  to  look  scarred  and  corrugated; 
in  the  aged  its  surface  resembles  the  convolutions  of  the  brain. 

In  diseased  conditions,  such  as  inflammation   and  conges- 


56  DISEASES    OF   WOMEN. 

tion  of  the  ovary,  there  is  some  interference  with  the  rupture  of 
the  Graafian  follicle,  and  the  ovarian  form  of  dysmenorrhea  re- 
sults. This  form  is  best  diagnosed  by  the  time  of  the  pain  in 
reference  to  the  beginning  of  the  flow;  it  preceding  the  flow  from 
four  to  six  days.  As  soon  as  this  follicle  ruptures,  it  is  filled  with 
a  yellowish  fluid  which  is  gradually  absorbed,  resulting  in  a  scar, 
which  is  called  a  corpus  luteum.  If  impregnation  does  not 
follow  the  rupture  of  the  follicle,  it  is  called  a  false  corpus 
luteum,  but  if  impregnation  does  take  place,  it  is  called  a  true 
corpus  luteum  and  is  not  readily  obliterated. 

The  ovary  is  a  very  common  seat  of  disease  and  a  favorite 
organ  for  operations.  The  function  of  the  ovary  is  to  mature 
and  expel  the  ®va,  and  regulate  menstruation,  therefore  any 
diseased  condition  affecting  this  function  will  result  in  sterility 
or  menstrual   disturbances,   especially  amenorrhea. 

Williams  speaks  of  an  internal  secretion  of  the  ovary,  that 
has  something  to  do  with  the  elaboration  of  the  blood.  The 
testes  have  an  internal  secretion,  and  it  is  generally  believed  the 
ovaries  likewise  elaborate  a  somewhat  analogous  product,  which 
plays  an  important  part  in  the  female  economy.  Such  a  thing 
is  possible  since  atrophy  of  the  rest  of  the  genitalia  follows  so  rap- 
idly after  removal  of  the  ovaries,  also  the  general  effect  is  quite 
marked;  a  weakening  or  lessening  of  physical  endurance 
being  most  common.  These  things  argue  against  removal  oi 
the  ovaries  for  trivial  diseases.  The  true  osteopath  attempts 
to  save  them  before  advising  their  removal. 

The  blood  supply  comes  from  branches  of  the  ovarian 
artery,  some  six  or  eight  in  number,  which  enter  the  ovary  at 
the  hilum;  the  veins  follow  the  arteries  and  enter  the  pampin- 
iform plexus  in  the  broad  ligament,  from  which  the  blood  is 
carried  by  the  ovarian  veins  to  the  renal  on  the  left  side,  and  in- 


ANATOMY. 


57 


ferior  vena  cava  on  the  right.  On  account  of  the  presence  of 
the  rectum  on  the  left  side  and  the  left  ovarian  vein  entering  the 
renal  at  right  angles,  and   also  the  left  vein   having   no  valve, 

THE  LEFT  OVARY  IS  MORE  COMMONLY  DISEASED  THAN  THE  RIGHT. 


Fig.  31. — Lymphatics  of  vagina  and  uterus. 

The  lymphatic  vessels  empty  into  the  lumbar  glands.  The 
nerve  supply  comes  from  the  inferior  hypogastric  plexus, 
by  way  of  the  uterine  and  the  ovarian  plexus,  the  latter  of 
which  receives  branches  from  the  renal  and  aortic  plexuses.  The 
lierves  supplying  the  iliac  fossae,  the  tenth  and  eleventh  in- 
tercostal, connect  with  the  above  plexuses;  in  fact,  the  source 
of  nearly  all  the  nerve  force  for  all  the  above  named  nerves  and 
plexuses  is  the  tenth  and  eleventh  segments  of  the  thoracic 
SPINAL  CORD.  In  most  all  ovarian  affections,  especially  conges- 
tion and  inflammation,  the  pain  is  felt  in  the  abdominal  wall  in 
the  area  corresponding  to  the  distribution  of  the  tenth  and 
eleventh  intercostal  nerves,  which  is  that  part  of  the  iliac  fossa  on  a 


58  DISEASES    OF    WOMEN. 

level  with  the  anterior  superior  spines  of  the  ilium.  This  explains 
how  vertebral  lesions  in  the  lower  thoracic  area  affect  the  ovaries, 
or  in  other  cases,  produce  pains  similar  to  those  that  accompany 
ovarian  diseases  and  which  are  often  mistaken  for  such  diseased 
conditions.  The  peritoneum  in  relation  is  supplied  by  the  above 
mentioned  nerves.  In  ovaritis  nearly,  if  not  all,  the  pain  is  in 
the  parietal  layer  of  the  peritoneum  which  forms  a  part  of  the 
abdominal  wall. 

Byford  mentions  that  a  part  of  the  nerve  supply  to  the  ovary, 
connects  with,  or  is  derived  from,  the  superior  mesenteric  plexus. 
This  plexus  supples  in  the  main,  all  of  the  small  intestines,  hence 
the  cramping  in  ovarian  colic  is  often  referred  to  the  "stomach." 
Perhaps  the  pain  is  really  there,  but  in  most  cases  the  chances 
are  it  is  a  "referred"  pain.  Fig.  26  illustrates  the  pelvic  organs, 
iti  situ,  as  seen  from  above. 

THE  PAROVARIUM.  Connected  with  the  ovary  is  a  tri- 
angular group  of  small  tubules  known  as  the  parovarium,  which 
is  the  remnant  of  the  Wolffian  body.  It  is  rudimentary  and  has 
no  function.  It  is  of  interest  to  gynecologists  in  that  it  is  the 
seat  of  various  growths,  especially  of  the  cri'STic  variety. 

THE  FEMALE  URETHRA.  The  female  urethra  is  a  mem- 
branous canal  from  one  to  one  and  one-half  inches  long,  which 
forms  an  outlet  to  the  bladder.  It  has  three  coats;  an  outer  or 
connective  tissue,  a  middle  or  muscular  and  an  inner  or  mucous 
coat.  Vascular  papillae  are  found  in  the  mucous  membrane, 
and  mucous  glands  are  quite  numerous. 

In  nullipara,  the  long  axis  is  straight,  while  in  multiparous 
women  it  is  slightly  concave  with  its  concavity  upward  and  back- 
ward, when  the  patient  is  in  the  dorsal  position.  This  curve  is 
increased  in  cystocele  and  frequently  to  such  an  extent  that  a 
sound  or  bougie  has  to   be   used    to    straighten    the  urethra,  if 


ANATOMY.  59 

there  is  much  retention  of  urine  or  if  micturition  is  otherwise  in- 
terfered with.  The  urethra  is  very  distensible  which  is  due 
to  the  thinness  of  its  walls,  they  being  one-third  thinner  than  the 
walls  of  the  male  urethra. 

The  external  opening  is  called  the  meatus  urinarius,  which 
is  in  about  the  center  of  the  vestibule.  It  presents  a  puckered 
appearance  and  in  multipara ,  the  mucous  membrane  is  often 
found  to  be  everted  and  protruding  at  the  meatus.  This  is  the 
result  of  subinvolution  of  the  anterior  vaginal  wall  and  of  the 
urethra  itself.  This  is  surrounded  with  various  glands  of  which 
Skene's  gland  is  the  most  important.  Sometimes  it  is  the  seat 
of  a  vascular  tumor  called  a  caruncle,  which  is  very  painful. 

In  the  introduction  of  the  catheter  if  your  are  certain  the 
parts  are  clean,  inspection  is  not  necessary,  otherwise  it  is.  This 
is  a  comparatively  easy  operation,  the  calibre  of  the  female  ureth- 
ra being  much  larger  and  the  canal  shorter  than  in  the  male. 
It  is  smallest  at  the  meatus. 

It  is  the  seat  of  various  inflammatory  conditions,  both  simple 
and  specific,  which  give  rise  to  pain,  frequent  micturition  and 
vulvitis.  One  writer  takes  the  position  that  the  urethra  plays 
the  chief  part  in  orgasm.  He  says,  "whether  in  the  male  or 
female  the  urethra  is  the  part  in  which  the  orgasm  occurs;  in 
the  male  by  the  passing  of  jets  of  semen  over  the  mucous  mem- 
brane of  the  urethral  canal;  in  the  female  by  jets  of  mucus  from 
the  neck  of  the  bladder  through  the  urethra.  This  explains  the 
habit  in  some  individuals  of  passing  all  manner  of  objects  into 
the  urethra  and  even  masturbating  in  that  way."  Since  the 
nerve  supply  of  the  meatus  is  from  the  pudic .  the  above  state- 
ments are  made  quite  probable. 

THE  BLADDER.  The  bladder  is  a  hollow  muscular  organ, 
located  behind  the  symphysis   pubis  and  supported,  almost  en- 


60  DISEASES     OF    WOMEN. 

tirely,  by  the  anterior  vaginal  wall,  and  which  acts  as  a  re- 
ceptacle for  the  urine.  The  symphysis  pubis  is  in  relation  in 
front;  the  anterior  surface  of  the  uterus  posteriorly  and  superi- 
orly, and  upper  surface  of  the  vagina  inferiorly.  It  has  the  usual 
THREE  COATS,  peritoneal,  muscular  and  mucous.  The  muscular 
coat  at  the  neck  is  so  arranged  that  it  forms  a  loose  sphincter; 
SPHINCTER  VESICAE.  The  base  is  not  separated  by  peritoneum 
from  the  uterus  and  vagina  but  is  in  direct  contact,  hence  the 
explanation  of  the  frequency  of  fistulous  openings  between  blad- 
der and  vagina  or  uterus.  The  female  bladder  differs  slightly 
in  shape,  from  that  of  the  male,  the  antero-posterior  diameter 
being  shorter  and  the  transverse  longer.  The  capacity  of  the 
female  bladder  is  greater  than  that  of  the  male. 

It  has  three  openings,  two  for  the  entrance  of  the  ureters 
and  one  for  the  urethra.  At  the  triangle,  formed  by  the  entrance 
of  the  two  ureters,  is  located  the  trigone,  which  is  the  most  sen- 
sitive part  of  the  bladder.  The  uterus  partly  rests  upon  the 
bladder  and  is  changed  in  position  by  distention  or  collapse  of  that 
organ.  At  the  upper  extremity  is  attached  the  urachus  or  lig- 
ament of  the  bladder,  which  is  a  remnant  of  fetal  life.  Some- 
times the  urachus  does  not  close  and  the  urine  in  such  cases 
escapes  at  the  umbilicus. 

The  MICTURITION  CENTER  located  in  the  second  lumbar  seg- 
ment of  the  spinal  cord  controls  the  action  of  the  bladder.  If  an 
unnatural  pressure  is  exerted  on  the  bladder,  an  impulse  is  con- 
veyed to  the  center  and  then  transmitted  back  to  the  sphincter 
muscle  and  by  its  relaxation  coupled  with  contraction  of  the 
bladdere,  vacuation  follows.  On  this  account,  ante-deviations 
of  the  uterus,  by  producing  abnormal  or  unnatural  pressure  on 
the  bladder,  produce  frequent  micturition.  If  the  pressure 
is    constant,    painful   spasms   of   the   bladder  will   immediately 


ANATOMY.  61 

follow  micturition,  to  which  is  applied  the  term  tenesmus.  This 
is  especially  true  if  congestion  or  inflammation  of  either  is  pres- 
ent, which  makes  the  irritation  worse. 

The  bladder  is  an  air  tight  cavity  and  should  be  kept  as 
such;  and  the  practice  of  washing  out  the  bladder  in  case  of 
cystitis  is  to  be  condemned  in  most  cases,  it  being  almost  impossi- 
ble to  prevent  the  entrance  of  air  during  the  operation.  Even 
though  no  air  enters,  it  is  injurious  to  the  walls  of  the  bladder. 
In  the  introduction  of  a  catheter,  care  should  be  exercised  as  to 
the  lubricant  used,  lest  something  be  introduced  that  might  form 
a  nucleus  around  which  a  concretion  be  produced.  Glycerine 
and  vaseline  mixed  in  equal  parts  or  pure  vaseline  is  regarded 
as  the  best  lubricant. 

The  arteries  supplying  the  bladder  are  the  superior,  middle, 
and  inferior  vesical.  The  veins  form  plexuses  communicating 
with  those  of  the  uterus,  rectum  and  vagina,  and  empty  into  the 
internal  iliac.  The  nerves  come  from  the  hypogastric  plexus 
by  way  of  uterine  and  vesical,  and  directly  from  the  sacral  nerves. 

On  account  of  similarity  of  blood  and  nerve  supply  between 
the  uterus  and  bladder,  diseases  of  one  affect  the  other.     Lesions 
producing  disease  of  one  often  produce  disturbances  of  the  other. 
Often  the  worst  cases  of  bladder  trouble  are  directly  due  to 
uterine  disease. 

THE  RECTUM.  The  lowest  division  of  the  large  intestine 
is  called  the  rectum.  Although  the  word  rectum  means  straight, 
we  find  on  examination  there  are  several  curves  which  are  to  be 
considered.  It  enters  the  pelvis  just  in  front  of  the  left  sacro- 
iliac articulation;  it  goes  first  downward,  backward  and  inward, 
in  front  of  the  third  and  fourth  sacral  vertebrae,  to  the  median 
line.  After  it  has  reached  the  median  line,  it  turns  forward  and 
passing  between  the  sacro-uterine  ligaments,  it  lies  in    contact 


62  DISEASES   OF    WOMEN. 

with  the  lower  portion  of  the  viterus  and  upper  part  of  the 
vagina. 

The  uterus  in  retro-deviation  can  be  readily  felt  through 
the  anterior  wall  of  the  rectum.  It  is  capable  of  a  great  deal  of 
distention,  and  sometimes  an  accummulation  of  feces  might  be 
mistaken  for  a  fibroid  tumor  if  care  is  not  used  in  the  diagnosis. 

The  RECTUM  is  composed  of  three  coats,  peritoneal,  mus- 
cular and  mucous.  The  muscle  fibers  are  arranged  into  a  long- 
itudinal and  circular  layer.  At  the  upper  limit  of  the  ampulla 
or  dilated  portion,  which  is  on  a  level  with  the  attachment  of 
the  vagina  to  the  cervix,  the  circular  fibers  are  best  marked  and 
there  form  the  internal  sphincter  ani  muscle.  In  cases  of  con- 
stipation due  to  atony  of  the  rectal  walls,  and  such  cases  are 
common,  the  mucous  membrane  is  found  to  be  prolapsed  with 
transverse  folds  which  entirely  occlude  the  lumen. 

The  upper  portion  is  covered  with  peritoneum;  the  middle, 
in  front  only,  by  a  fold  which  forms  the  pouch  of  Douglas,  while 
the  lowest  portion  is  entirely  free  from  peritoneal  attachments. 
The  muscles  connected  with  the  rectum  are  the  two  sphincters 
and  levator  ani,  the  latter  pulling  the  rectum  and  perineum  for- 
ward and  upward.  An  interesting  fact  is  that  the  bowel 
develops  from  below  upward,  according  to  Dr.  Still,  meeting 
the  small  intestine,  which  is  developed  in  the  reverse  direction, 
at  the  cecum.  On  this  account  the  nerve  supply  comes  from 
the  lower  part  of  the  spinal  cord,  and  advantage  should  be  taken 
of  this  in  the   treatment  of  constipation. 

Relations.  The  rectum  lies  between  the  two  sacro-uterine 
ligaments,  (see  Fig.  25)  and  is  in  contact  with  the  left  ureter  and 
left  internal  iliac  artery,  having  the  left  ovary  in  front  and  lying 
in  relation  with  the  pyriformis  muscle  and  sacral  plexus.  In 
front  it  is  separated  from  the  uterus  by  the  pouch  of  Douglas 


ANATOMY. 


63 


and  sometimes  the  small  intestines.  In  distention  of  the  rectum 
produced  by  constipation,  the  uterus  is  forced  forward  and  the 
circulation  in  the  bowel  and  uterus  interfered  with.  Again,  in 
retro-deviations  of  the  uterus,  pressure  is  exerted  vipon  the  rec- 
tum, which  may  cause  constipation,  and  pain  or  numbness  in 
the  limbs,  this  being  on  account  of  the  pressure  against  the  sacral 
nerves.     Hemorrhoids,  both  internal  and  external,  may  also  re- 


FiG.  32— The  synipatlietic  nerve  t-upiil.v  to  the  jielx  ic   vis- 
cern . 

suit.  On  account  of  the  presence  of  the  rectum  on  the  left  side, 
and  especially  if  there  is  constipation,  the  left  ovary  is  more 
frequently  affected  than  the  right. 


64  DISEASES   OF   WOMEN. 

The  BLOOD  supply  is  from  the  superior  hemorrhoidal,  from 
the  inferior  mesenteric,  the  middle  hemorrhoidal,  from  the  in- 
ternal iliac;  and  the  inferior  hemorrhoidal  from  the  internal 
pudic.  The  veins  form  a  large  plexus  which  accompanies  the 
arteries.  A  part  of  the  blood  returns  by  way  of  inferior  and 
middle  hemorrhoidal  to  the  internal  iliac,  and  part  by  way  of 
the  hemorrhoidal  to  the  inferior  mesenteric  veins.  The  nerves 
are  mostly  from  the  sympathetic,  but  some  come  from  the  sacral 
plexus.  Quain  says:  "Experiments  on  animals  have  shown 
that  the  longitudinal  muscle  fibers  of  the  rectum  are  supplied 
with  motor  nerves  from  the  anterior  roots  of  certain  of  the  sacral 
nerves,  second  and  third,  which  nerves  also  supply  inhibitory 
fibers  to  the  circular  coat;  whereas,  the  fibers  of  the  hypogastric 
PLEXUS  which  supply  the  circular  muscular  tissue  with  motor 
fibers,  are  derived  from  white  rami-communicantes  of  the  an- 
terior roots  of  certain  of  the  lumbar  nerves, which  join  the  sym- 
pathetic chain  and  lose  their  medullary  sheath  before  passing 
to  their  distrbution  in  the  muscular  coat." 

The  rectum  acts  as  a  receptacle  for  the  feces.  Their  pres- 
ence STIMULATES  THE  SENSORY  NERVES  INNERVATING  THE  BOWEL, 

which  impulses  thus  set  up,  are  carried  to  the  defecation  center 
and  this  center  in  turn,  sends  an  impulse  back  to  the  muscles 
which  control  the  act  of  defecation.  Sometimes  lesions  exist 
which  tend  to  lessen  the  degree  of  irritability,  hence  there  must 
be  a  greater  irritant  in  order  that  impulses  may  be  originated 
and  in  such  cases,  constipation  results.  Again,  the  sensory 
nerves  may  be  irritated, thus  keeping  the  center  in  a  state  of  activ- 
ity, and  from  this  follows  diarrhea. 

In  practice,  the  close  sympathy  that  exists  between  the 
uterus  and  rectum  is  often  overlooked.  One  organ  reacts  on 
the  other,  and  on  this  account  various    rectal  affections 


ANATOMY.  65 

are  the  result  of  a  diseased  or  displaced  uterus,  and  the 
treatment  should  be  directed  to  it  instead  of  the  rectum.  This 
remark  especially  applies  to  the  condition  of  hemorrhoids,  which 
we  find  very  common  in  parous  women.  Pain  low  down  in  the 
left  iliac  fossa,  is  often  due  to  a  displaced  uterus  pressing  on  the 
rectum.  This  pain,  which  is  quite  constant,  may  be  as  low  as 
Pouparl'8  ligament.  Replacement  of  the  uterus  usually  gives 
immediate  relief. 

THE  PELVIC  PERITONEUM.  The  pelvic  peritoneum  is 
a  continuation  of  the  abdominal  peritoneum,  which,  like  a  cloth, 
covers  the  superior  portion  of  the  pelvic  organs,  folds  of  which 
drop  down  between  the  organs  forming  their  ligaments.  The 
peritoneal  sac  is  a  large  space  in  which  is  a  small  amount  of 
lymph  distributed  over  the  surface  for  the  purpose  of  lubrica- 
tion. The  lymphatic  vessels  collecting  the  lymph  eventually 
empty  into  the  receptaculum  chyli,  hence  obstruction  of  the 
thoracic  duct  will  cause  an  accumulation  of  lymph  in  the  peri- 
toneal cavity,  which  condition  is  called  ascites. 

Beginning  in  front,  the  peritoneum  extends  from  the  ab- 
dominal wall  to  the  top  of  the  bladder,  covering  its  posterior 
wall  down  to  the  level  of  the  internal  os  uteri,  and  forming  the 
vesico-uterine  ligament.  From  the  posterior  surface  of  the  bladder 
it  passes  to  the  anterior  wall  of  the  uterus,  covering  the  anterior 
wall  as  far  down  as  the  internal  os;  it  then  covers  the  edges, 
forming  the  broad  ligaments,  and  posterior  surface  of  the  uterus, 
going  as  low  as  the  upper  portion  of  the  vagina,  from  which  it 
passes  to  the  rectum,  thereby  enclosing  a  space  called  the  pouch 
OF  Douglas;  the  lowest  point  of  the  peritoneum.  This  pouch 
is  partially  filled  with  small  intestines  and  contains  the  ovary 
when  prolapsed.  The  peritoneum  covers  the  anterior  portion 
of  the  middle,  third,  and  surrounds  the  entire  upper  portion  of 
the  rectum. 


66  DISEASES   OF    WOMEN. 

The  peritoneum  in  the  female  is  perforated  by  the  en- 
trance of  the  Fallopian  tubes  and  on  account  of  this,  infection 
may  be  transmitted  directly  into  the  peritoneal  cavity;  also  there 
is  a  possibility,  as  mentioned  before,  of  the  injection  of  fluids 
into  the  peritoneal  cavity  in  intra-uterine  douches,  especially 
when  the  tubes  are  diseased.  The  peritoneum  has  great  ab- 
sorptive qualities  and  in  case  of  retention  of  menses,  peritonitis 
may  result.  The  rapidity  of  absorption  is  partly  explained  by 
the  great  number  of  lymphatic  vessels,  the  extensive  area  of 
membrane  drained,  and  by  the  peristalsis  of  the  bowels  which 
disseminates  the  toxic  material. 

The  peritoneum  is  very  sensitive  and  in  peritonitis,  the  least 
movement  produces  excruciating  pain.  The  most  sensitive  por- 
tion is  that  in  relation  with  the  small  intestines.  A  sudden  dis- 
placement of  the  uterus  usually  sets  up  an  acute  attack  of  per- 
itonitis. The  author  has  treated  a  number  of  cases  of  fevers 
which  were  due  to  a  displacement  of  the  uterus  which  was  affect- 
ing the  peritoneum. 

During  pregnancy  the  peritoneum  is  hypertrophied  and 
stripped  from  off  the  bladder.  It  should  undergo  the  process 
of  involution  after  labor  similar  to  that  of  the  pelvic  viscera. 
Often  this  does  not  occur,  and  thus  it  remains  stretched  and 
as  a  result  the  uterus  is  too  freely  movable  and  can  be  pushed 
from  one  side  of  the  pelvic  cavity  to  the  other.  On  this  account 
the  uterus  will  be  found  to  be  in  a  different  position,  nearly  every 
time  it  is  examined,  for  quite  awhile  after  delivery. 

In  inflamed  conditions  of  the  uterus  the  disease  may  ex- 
tend to  the  neighboring  peritoneum  and  there  set  up  a  condi- 
tion of  perimetritis  or  local  peritonitis,  this  Usually  terminating 
in  adhesions.  These  adhesions  are  in  the  peritoneal  cavity  and 
care  should  be  taken  in  their  treatment  lest  there  be  hemorrhage, 


ANATOMY. 


67 


fermentation  of  the  blood  and  diffuse  peritonitis.  The  function 
of  the  peritoneum  is  to  anchor  or  support,and  to  permit  of  free 
motion  of,  the  viscera  surrounded  by  it. 

THE  PELVIC  FLOOR.     The  pelvic  floor,  which  is  com- 


FiG.  33. — Pelvic  floor  showini;  openingn  and  illrection  of  muRcle  fibers. 

posed  of  muscles,  fascia,  fat  and  connective  tissue,  closes  the 
lower  opening,  of  the  true  pelvis.  It  is  usually  divided  into  an 
ANTERIOR,  or  puMc  Segment,  and  a  posterior  or  sacral  segment. 
The  anterior  segment  is  triangular,  being  attached  to  the  pel- 
vic bones  in  front  and  includes  the  structures  lying  between  the 


68  DISEASES    OF    WOMEN. 

symphysis  and  the  vaginal  orifice.  The  urethra  and  anterior 
vaginal  walls  with  the  intervening  fibrous  tissues,  go  to  form  the 
larger  part  of  this  portion  of  the  floor. 

The  sacral  segment  includes  the  structures  between  the 
vaginal  orifice  and  the  posterior  pelvic  wall.  Comprised  in  this 
are:  the  perineal  body,  posterior  vaginal  wall,  muscles  and  con- 
nective tissue.  Both  segments  taken  together  comprise  the 
perineum.  The  principal  muscle  is  the  levator  ani,  attached 
anteriorly  to  the  symphysis  pubis  and  posteriorly  to  the  coccyx. 
It  is  a  swing-like  muscle,  which,  uniting  with  its  fellow  of  the 
opposite  side,  forms  the  most  important  part  of  the  pelvic  floor. 
It  is  called  by  some  the  pelvic  diaphragm;  by  its  contraction  it 
assists  the  forcing  of  the  blood  through  the  uterus,  helps  to  expel 
fecal  matter  and  most  inmportant  of  all,  it  is  the  principal 
force  which  holds  the  posterior  vaginal  wall  against 
the  anterior;  in  short,  it  pulls  the  perineal  body  forward  and 
upward. 

The  other  muscles  of  the  pelvic  floor  are  from  without  in- 
ward; the  transversus  perinei,  the  ischio-cavernosus,the  sphincter 
ani,  the  sphincter  vaginae,  the  coccygeus  and  the  levator  ani,  the 
last  mentioned  muscle  being  located  deepest.  Although  these 
various  muscles  have  been  dissected  out,  as  separate  muscles,  yet 
their  function  is  practically  the  same,  that  is,  they  act  together 
in  pulling  the  perineum  forward  and  upward. 

The  perineal  body  is  composed  of  the  tissues  comprised 
between  the  rectum  and  the  posterior  vaginal  wall.  In  it  are 
inserted  most  of  the  muscles  of  the  pelvic  floor.  Upon  its  in- 
tegrity depends  the  apposition  of  the  vaginal  walls;  and  upon 
this  depends  the  position  of  the  uterus,  at  least  its  height.  In 
parturition  this  body  may  be  lacerated  through  ignorance  Or 
carelessness,  thus  weakening  the  keystone  of    the  pelvic    floor 


ANATOMY.  69 

I  know  of  few  instances  in  which  the  osteopath  was  guilty  of  per- 
mitting laceration  of  this  body  deep  enough  to  require  stitches, 
the  prevention  of  laceration  of  the  perineum  being  one  of  the 
claims  for  the  superiority  of  osteopathic  obstetrics  over  all  other 
methods.  The  author,  out  of  over  three  hundred  cases,  has  not 
had  a  case  in  which  the  laceration  involved  the  muscle  fibers  to 
such  an  extent  that  an  operation  was  necessary  and  only  in  a 
very  small  per  cent,  of  cases  was  there  any  laceration  at  all. 

The  perineum  includes  all  the  structures  between  the  coccyx, 
tuber  ischii  and  the  pubes.  Sometimes  this  is  confused  with  the 
perineal  body,  but  is  a  broader  term,  and  includes  the  perineal 
body.  The  pelvic  floor  is  the  principal  support  of  the  uterus 
and  upon  its  integrity  and  tonicity  depends  the  position  of 
the  uterus.  There  is  a  certain  amount  of  physiological  descent 
of  the  pelvic  floor  under  different  conditions.  In  respiration 
the  floor  alternately  ascends  and  descends.  In  coughing,  laugh- 
ing or  in  any  other  condition  involving  an  increase  of  intra-abdom- 
inal pressure,  it  is  forced  downward.  Deep  breathing,  if  per- 
formed regularly  and  evenly,  strengthens  it. 

In  weak  people,  that  is,  in  a  condition  of  general  physical 
weakness,  the  floor  remains  in  a  position  of  descent.  The 
TONE  of  the  floor  depends,  partly  at  least,  on  the  general  condi- 
tion, and  on  this  account  there  is  a  great  deal  of  difference  in 
the  tonicity  of  the  pelvic  floor  in  different  people.  For  instance , 
if  I  find  the  vagina  large,  a  leucorrheal  condition  and  the  tissues 
soft,  I  at  once  suspect  a  displacement  of  the  uterus.  If  the  pel- 
vic floor  is  relaxed,  the  two  walls  of  the  vagina  will  not  be  held 
in  apposition  and  air  mil  enter  the  vaginal  canal,  which  de- 
stroys the  equilibrium  of  the  intra-pelvic  pressure. 

The  NERVE  SUPPLY  of  the  pelvic  floor  is  derived  principally 
from  the  pudic.     The  third  and    fourth  sacral  nerves,  anterior 


70  DISEASES    OF    WOMEN. 

divisions,  also  send  filaments  to  it.  From  the  nature  of  the 
nerve  supply,  especially  when  the  most  important  function  of 
these  nerves  is  remembered,  a  connection  between  sexual  im- 
potence, or  other  similar  disorders,  and  the  condition  of  the  pel- 
vic floor  can  readily  be  seen.  Excessive  venery  produces  a  re- 
laxation of  pelvic  floor.  The  converse  is  also  true.  A  rigid 
pelvic  floor  usually  is  indicative  of  an  irritated  condition  of  the 
sexual  apparatus.  Hemorrhoids  cause  an  increase  in  sexual 
passion.     The  above  is  true  of  the  male  as  well  as  of  the  female. 

To  STRENGTHEN  the  pelvic  floor,  restore  the  normal  nerve 
supply  by  correcting  lesions,  prohibiting  excessive  venery  and 
by  exercising  the  muscles  forming  the  floor.  Knee  parting  against 
resistance  is  very  good  to  develop  these  muscles.  This  can  best 
be  done  in  the  sitting  posture.  The  restraining  bowel  move- 
ment is  also  very  good.  In  this,  the  bowel  is  drawn  upward, 
and  the  muscles  of  pelvic  floor  contracted  by  will  power.  These, 
like  other  muscles,  strengthen  from  use,  and  if  the  above  men- 
tioned exercise  is  kept  up,  the  pelvic  floor  can  be  materially 
strengthened.  Activity  is  necessary  for  muscular  develop- 
ment. 

THE  PELVIC  CONNECTIVE  TISSUE.  The  pelvic  con- 
nective tissue  surrounds  the  pelvic  organs  and  fills  in  the  spaces 
between  the  muscles  that  are  found  in  the  pelvic  cavity.  Its 
function  is  that  of  steadying  the  pelvic  organs,  which,  at  every 
step,  are  moved.  From  its  elastic  character,  jar  from  sudden 
movements  of  the  body  as  in  running,  is  broken.  It  also  dis- 
tributes the  nerves  and  blood  vessels.  It  permits  of  a  great  de- 
gree of  stretching,  upward  as  in  pregnancy,  or  downward  as  in 
prolapse,  without  serious  impairment  of  either  vessels  or  nerves. 
Inflammation  of  the  uterus  readily  spreads  to  it,  which  sets  up 
a  secondary  inflammation  called  cellulitis  or  parametritis.     Some- 


ANATOMY. 


71 


times  it  furnishes  the  location  for  a  deep-seated  abscess,  which 
is  very  obscure  and  hard  to  diagnose.  I  once  saw  a  case  of  pel- 
vic cellulitis  which  had  been  treated  for  some  months  for  ma- 
laria; there  being  rigors,  fever  and  sweats.  A  diagnosis  can  be 
made    by  locating  the     abscess  by  careful  examination.     A 

HURRIED  EXAMINATION  SO  OFTEN  LEADS  TO  MISTAKES  IN  DIAG- 
NOSIS. 

THE  BONY  PELVIS.     The  bony  pelvis  is  formed  by  the 
articulation   of  four  bones,   the   two  innominate,   sacrum,   and 


Fig.  34. — The  bony  pelvis  with  the  ligaments  attached. 

coccyx,  each  of  which,  in  turn,  is  composed  of  a  number  of  seg- 
ments that  were  united  early  in  life.  The  parts  of  the  innomi- 
nate bone,  the  ilium,  pubis  and  ischium  unite  quite  early,  the 
segments  of  the  sacrum  unite  next  in  order,  while  the  segments 
composing  the  coccyx  remain  movable  until  past  middle  life. 

The  space  enclosed  by  these  bones  is  called  the  pelvic  cav- 
ity and  is  divided  into  two  parts,  the  true  and  false  pelvic  cav- 


72  DISEASES   OF    WOMEN. 

ities,  the  partition  between  the  two  corresponding  to  a  plane 
passing  through  the  sacral  promontory  and  the  upper  part  of 
the  symphysis  pubis. 

The  true  pelvic  cavity,  roughly  speaking,  may  be  compared 
to  an  obliquely  truncated  cone  with  its  greatest  height  poster- 
iorly, which  measures  a  little  more  than  four  inches,  while  the 
anterior  portion  measures  less  than  two  inches.  With  the  woman 
in  an  erect  position,  the  upper  portion  faces  forward  and  up- 
ward and  the  lower  portion  faces  downward  and  forward,  which 
facts  indicate  that  the  canal  or  tract  is  a  curved  one. 

The  walls  of  the  true  pelvic  cavity  are  composed  of  bony 
muscular,  and  ligamentous  tissues.  Posteriorly  it  is  bounded 
by  the  anterior  surface  of  the  sacrum;  laterally  by  the  ischial 
bones  and  sacro-sciatic  ligaments  and  muscles,  while  anteriorly 
it  is  bounded  by  the  ascending  rami  of  the  ischia,  pubic  bones, 
and  membrane  covering  the  obturator  foramina.  This  cavity 
in  the  female  contains  some  of  the  small  intestines ;  the  bladder, 
the  uterus  with  its  appendages,  viz.,  the  Fallopian  tubes,  ovaries 
and  their  ligaments;  blood  vessels,  lymphatics  and  nerves.  Per- 
itoneum or  connective  tissue  surrounds  each  so  that  the  cav- 
ity is  securely  filled,  there  being  not  a  portion  but  that  is  filled 
in  with  tissue  of  some  sort. 

The  false  pelvic  cavity  is  bounded  below  by  the  plane  men- 
tioned above  as  forming  the  superior  boundary  of  the  true  pel- 
vic cavity  and  comprises  the  space  between  the  iliac  bones.  It 
serves  as  a  receptacle  for  the  intestines.  Sometimes  the  uterus 
and  bladder  are  forced  up  in  this  cavity;  the  uterus  from  en- 
largement due  to  pregnancy,  growths  or  congestion,  the  bladder 
from  pregnancy  or  overdistention. 

The  SACRAL  PROMONTORY  Can  readily  be  felt  on  abdominal 
palpation  except  in  the  very  obese.  •  In   downward   displace- 


ANATOMY.  73 

ments,  of  the  upper  part  of  the  sacrum,  it  is  made  more  promi- 
nent. Sometimes  the  uterus  is  incarcerated  below  the  prom- 
ontory and  adheres  to  the  sacrum. 

The  sacrum  was  formerly  regarded  as  the  "keystone"  of 
the  pelvis  but,  as  Matthew  Duncan  has  shown,  this  is  erroneous. 
It  represents  an  inverted  keystone,  since  it  is  wider  along  its 
anterior  inferior  surface  than  along  its  posterior  superior  sur- 
face, so  that  it  would  tend  to  slip  downward  under  the  super- 
imposed weight  of  the  body  were  it  not  held  in  position  by  the 
strong  SACRO-iLiAC  ligaments. 

Certain  imaginary  planes  are  constructed  through  the  pel- 
vis for  the  purpose  of  locating  or  describing  any  given  part.  The 
plane  of  the  inlet  passes  through  the  sacral  promontory  and 
symphysis,  forming  an  angle  of  about  60  degrees  with  the  hor- 
izon when  the  patient  is  in  an  erect  posture.  Innominate  lesions 
alter  this  plane.  A  backward  rotation  of  the  ossa  innominata 
is  the  lesion  most  frequently  found  affecting  this  plane.  The 
plane  of  the  outlet  is  determined  by  the  tip  of  the  coccyx  and 
the  lower  part  of  the  symphysis. 

The  diameters  of  the  pelvis  vary  in  different  individuals, 
and  in  different  races.  The  internal  conjugate  diameter  of 
the  inlet  is  approximately  four  and  a  half  inches;  the  external 
conjugate,  seven  and  a  half;  the  interspinal  diameter,  or  dis- 
tance between  the  two  anterior  superior  spines,  averages  nine 
inches.  This  diameter  is  the  most  variable  of  all,  the  degree 
of  flare  of  the  iliac  bones  causing  the  variation. 

The  pelvic  bones  form  four  .joints.  The  symphysis  pubis 
unites  the  bones  anteriorly,  and  consists  of  fibro-cartilage,  and 
is  made  more  secure  by  an  anterior,  a  superior  and  an  inferior 
ligament.  In  the  young,  and  during  pregnancy,  a  variable 
amount   of   motion   exists   at   this   articulation.     A  synovial 


74  DISEASES    OF    WOMEN. 

membrane  can  be  demonstrated  in  the  above  mentioned    kinds 
of  cases. 

The  bones  separate  slightly  during  parturition,  the  degree 
depending  almost  entirely  on  the  age  of  the  patient.  On  this 
account  the  second  stage  of  labor  is  easier  in  young  primiparae 
than  in  primiparae  who  are  thirty  or  more  years  of  age.  The 
other  articulations  are  really  of  greater  importance  in  parturi- 
tion than  the  symphysis  pubis.  Dislocations  occur  oftener  in 
young  primiparae  than  in  other  classes,  on  account  of  greater 
mobility  of  this  and  the  other  pelvic  joints. 

The  sacro-iliac  articulation  is  usually  described  as  a  syn- 
chondrosis, but  I  believe  it  belongs  with  the  true  joints,  since  a 
synovial  membrane  exists.  These  articulations  have  a  greater 
amount  of  motion  than  the  symphysis.  The  degree  of  motion 
depends  upon  the  development  of  a  synovial  membrane,  age  of 
patient  and  condition  of  the  ilio-femoral  and  sacro-iliac  ligaments. 
In  parturition ,  the  sacrum  is  supposed  to  rotate  slightly. 
Although  this  movement  is  slight,  labor  is  made  quite  consider- 
ably easier  by  it.  Any  lesion  of  either  the  sacrum  or  innomi- 
nata  will  affect  this  articulation.  Although  it  is  quite  a  secure 
joint  and  well  protected  by  muscles  and  ligaments,  lesions 
occurring  at  labor  or  from  other  causes,  especially  trauma,  are 
quite  common. 

It  is  rare  to  find  the  two  innominata  the  same  height.  In 
right  handed  persons  in  whom  the  right  half  of  the  body  is  used 
more  than  the  left,  the  corresponding  side  of  the  pelvis  is  often 
better  developed  than  the  other.  Ordinarily  this  irregularity 
has  a  PATHOLOGICAL  SIGNIFICANCE,  and  points  to  a  lesion  at  the 
sacro-iliac  articulation.  Dressmakers  often  discover  in  cus- 
tomers that  one  hip  is  higher  than  the  other.' 

The  sacro-coccygeal  articulation  is  much  more  freely  mov- 


ANATOMY.  75 

able  than  any  of  the  other  pelvic  joints.  It  is  subject  to  injury 
from  falls  astride  an  object,  from  kicks,  or  blows  directly  on  the 
sacrum  or  coccyx.  In  forward  rotation  of  the  upper  part  of  the 
sacrum,  this  articulation  is  thrown  into  greater  prominence  on 
account  of  the  lower  part  of  the  sacrum  being  forced  backward. 
This  carries  the  upper  part  of  the  coccyx  back,  but  the  muscles 
and  tissues  attached  to  the  tip  draw  it  forward,  or .  at  least 
hold  it  in  normal  position.  Often  we  blame  the  coccyx 
for  the  disturbance  when  in  reality,  the  sacrum  is  at  fault. 

Posteriorly  the  contour  of  the  pelvis  is  determined  by  the 
development  of  the  glutei  muscles.  Generally  speaking,  the  better 
developed  these  muscles,  the  better  developed  the  genital  organs, 
this  not  being  true  in  obesity.  The  two  sides  of  the  buttocks 
should  be  carefully  compared.  Often  one  is  larger  than  the 
other,  indicating  sciatica  or  an  innominate  lesion. 


76'  DISEASES     OF    WOMEN. 


GENERAL  CAUSES  OF  DISEASE. 


THE  CAUSES  of  female  disease  are  divided  into  the  predis- 
posing and  the  exciting.  The  predisposing  causes  are  usually 
chronic,  and  include  heredity,  poor  development,  environment, 
dress,  habits  and  lesions,  the  last  named  being  the  most  im- 
portant from  the  osteopathic  standpoint.  Education,  or  rather 
the  methods  pursued  in  getting  it,  is  an  important  factor  in  the 
etiology  of  pelvic  diseases.  The  worst  feature  is  the  length  of 
school  hours,  the  competition,  lack  of  exercise  and  position  of 
pupils  while  seated  at  their  desks.  The  last  mentioned  cause  is 
very  important  and  one  that  is  overlooked,  or  at  least  minimized, 
by  the  old  school  physicians.  Usually  the  desk  is  too  low  and 
the  pupil  bends,  or  rather  humps,  forward  over  her  book,  or  in 
the  case  of  the  younger  pupils,  it  is  too  high.  In  writing,  one 
shoulder  is  elevated  and  the  spine  assumes  an  abnormal  curve, 
usually  to  the  right  and  back,  thus  predisposing  to  a  right  scoliosis 
and  kyphosis.  Thus  this  position  repeatedly  assumed,  affects 
the  normal  curve  of  the  spine,  which  is  usually  soon  replaced  by 
abnormal  ones.  In  the  lumbar  region  especially,  the  spine  is 
posterior.  The  pelvic  viscera  are  necessarily  weakened  and  as  a 
result,  predisposed  to  disease.  The  explanation  is,  that  the  lumbar 
spinal  cord  and  its  nerves  control  the  pelvic  viscera. 

Potter,  recognizing  some  of  the  defects  in  our  educational 
system,  suggests:  "For  girls  between  twelve  and  sixteen,  study 
hours  or  school  work  be  restricted  to  four  hours  daily;  that  dur- 
ing each  catamenial  period,  girls  should  indulge  in  much  mental 
and  bodily  repose;  and  that  during  the  school  period  especially. 


GENERAL    CAUSES    OF    DISEASE. 


77 


Fi(i.  35.— (iirl  writing  at  deslv  that  is  too  liigli,  showing  effect  on  spine.     (Prom  photo) 


78  DISEASES    OF    WOMEN. 

which  is  the  period  of  most  active  growth,  girls  should  be  pro- 
vided with  an  abundance  of  wholesome  food.  The  dress  should 
be  constructed  with  reference  to  relieving  the  waist  line  of  all 
weight  and  pressure." 

The  EXCITING  CAUSES  are  many,  such  as  exposure  during 
menstruation,  falls,  strains,  overwork  and  emotional  disturb- 
ances. In  most  cases  both  a  predisposing  and  an  exciting  cause 
are  present. 

HEREDITY.  Heredity  is  usually  named  as  a  predisposing 
cause  of  female  disease.  The  defect  existing  in  the  mother  may 
be  transmitted  to  a  daughter,  especially  if  there  is  a  malforma- 
tion or  syphylitic  disease.  Again,  if  the  mother  is  a  sufferer 
from  a  chronic  uterine  disease,  the  weakness  or  predisposition 
to  pelvic  disease  may  be  transmitted.  I  think  this  is  the  true 
explanation  of  the  part  heredity  plays  in  disease;  that  is,  the 
WEAKNESS,  NOT  THE  DISEASE,  is  transmitted.  On  this  account 
it  is  sometimes  well  to  get  a  history  of  the  case  and  to  ascertain 
if  a  similar  condition  existed  in  the  mother;  if  such  is  found  the 
prognosis  is  not  so  good.  It  must  be  also  noted  that  children  of 
parents  advanced  in  life  at  the  time  of  their  procreation  are,  as 
a  rule,  less  vigorous  than  those  engendered  in  younger  years. 
Pexual  intercourse  indulged  in  to  any  great  degree  after  quick- 
ening, undoubtedly  has  an  evil  influence  on  the  offspring. 
Sexual  perverts  result.  Nymphomania,  or  its  opposite  sexual 
repugnance,  is  often  developed  in  the  offspring  when  the  above 
mentioned  practices  are  persisted  in.  The  thoughts  and  actions 
of  the  pregnant  mother  influence  the  mental  and  physical  develop- 
ment of  the  fetus  in  utero.  Some  authors  state  that  actual 
diseases  in  offspring  follow  marital  relations  during  preg- 
nancy. The  offspring  of  mothers  who  had  exhausted  all  means 
of  preventing  pregnancy,  the  child  being  an  unwelcome  one, 


GENERAL    CAUSES    OF    DISEASE.  79 

early  in  life  begin  to  show  the  prenatal  influences  that  were  brought 
to  bear.  The  child  is  cross,  even  vicious,  this  being  the  mental 
effect,  while  in  some,  there  is  a  physical  effect  in  that  the  child 
is  marked  or  the  pelvic  organs  are  perverted  or  weak. 

One  important  case  which  shows  the  physical  effect  of  pre- 
natal INFLUENCE,  occurs  to  me.  The  mother  throughout  term 
complained  of  a  severe  backache  in  the  lower  dorsal  region.  The 
child  had  such  a  weak  spine  that  at  the  age  of  four  years  it  was 
unable  to  sit  up,  and  died  in  a  short  time  from  malnutrition.  On 
examination  of  the  child  a  lesion  consisting  of  a  separation,  was 
noticeable  in  the  lower  dorsal  region.  The  pain  left  the  mother  im- 
mediately on  birth  of  the  child.  Possibly  bony  lesions  were  pres- 
ent in  both  mother  and  child,  the  latter  being  injured  at  birth, 
which  is  frequently  the  case,  it  then  being  only  a  coincidence. 

The  importance  of  proper  care  of  the  pregnant  woman 
is  not  sufficiently  emphasized,  since  the  disposition,  traits,  in- 
clinations, mentality,  in  fact  the  entire  make-up  of  the  child  is 
undoubtedly  controlled,  to  a  great  degree,  by  prenatal  influ- 
ences of  parents,  especially  the  mother. 

The  PHYSICAL  influences  which  are  manifest  by  disease  are 
the  ones  which  in  reality,  come  in  the  scope  of  this  work.  Sexual 
perverts,  nymphomania,  masturbation,  ovarian  and  uterine 
diseases  usually  classed  as  "female  weakness"  are  the  principal 
effects  on  the  girl  when  such  diseases  and  conditions  exist  in  the 
mother  during  term. 

Civilization  has  been  given  as  an  explanation  for  the  pre- 
valence of  pelvic  disorders.  In  the  more  highly  civilized,  the 
mind,  brain  and  nervous  system  are  developed  at  the  expense 
of  the  other  elements  of  her  physical  organism.  Childbirth  is 
comparatively  easy  in  the  aboriginal  woman  because  the  pelvis 
is  large  and  the  fetal  head  small.     Although  the  above  state- 


80  DISEASES    OF    WOMEN. 

ments  are  generally  admitted  as  being  true,  civilization  should 
not  be  accredited  too  much  in  the  production  of  pelvic  disease. 
The  most  important  point  is  that  civilization  tends  to  lessen  physi- 
cal development  and  increase  the  mental.  If  only  a  happy  med- 
ium could  be  struck,  that  is  the  physical  be  developed  by  work 
or  proper  exercise  along  with  the  mind,  civilization  as  a  cause  of 
disease,  would  be  eliminated. 

ARREST  OF  DEVELOPMENT.  Up  to  the  time  of  puberty 
the  internal  female  organs  are,  or  should  be,  quiescent.  At 
the  time  of  puberty  there  is  a  great  change  and  increase  in 
the  nerve  distribution  to  the  pelvic  organs.  These  organs  be- 
come VASCULAR  and  commence  to  perform  their  physiological 
functions  of  ovulation  and  menstruation.  Since  the  pelvic 
organs  develop  at  puberty  and  require  at  this  time  a  large  amount 
of  nerve  force,  this  nervous  energy  should  not  be  directed  into 
other  channels,  or  there  will  be  some  interference  with  the  de- 
velopment of  the  genital  organs.  If,  at  this  period,  the  young 
girl's  nerve  force,  which  is  taxed  to  its  limit  in  the  full  de- 
velopment of  her  organs,  is  deflected  by  hard  study  or  work 
TO  OTHER  organs  OR  PARTS,  disease  will  result.  The  sympa- 
thetic or  ganglionic  nerves  are  the  regulators  of  organic  life,  and 
form  the  great  channel  for  nerve  distribution  to  the  organs. 
When  in  perfect  action  we  have  health;  when  impaired,  disease; 
and  when  their  influence  is  entirely  suspended,  death  forows. 
They  carry  nutrition,  the  smallest  capillary  being  covered  with 
sympathetic  filaments.  If  this  nutrition  is  used  to  develop  nerve 
cells  and  muscle  fibers  instead  of  supplying  the  now  developing 
pelvic  organs,  non-development,  or  other  disturbances  as  'stated 
above,  will  ensue. 

There  are  several  conditions  which  are  responsible  for  this 
perverted  condition  of  nutrition  of  the  pelvic  organs.     The  in- 


DISEASES    OF    WOMEX.  81 

tense  rivalry  amongst  the  young,  (those  who  have  reached  the 
age  of  puberty)  and  the  competition  which  leads  to  over-study, 
result  in  the  building  up  of  the  brain  at  the  expense  of  the  physi- 
cal; the  genitalia  on  account  of  their  change,  being  the  important 
parts  to  suffer.  Physical  over- work  has  a  similar  effect.  Ac- 
cidents, either  from  direct  injury  to  the  part  or  resulting  in  the 
formation  of  spinal  lesions,  produce  a  perverted  nutrition  of  the 
ovaries  and  uterus,  which  amounts  to  an  arrest  of  development. 
This  is  especially  true  in  cases  of  dysmenorrhea. 

Many  a  woman  dates  her  trouble  back  to  the  commence- 
ment of  menstruation,  and  I  find  in  getting  a  record  of  these 
cases  that  overwork,  either  mental  or  physical,  just  before  or  at 
puberty,  is  one  of  the  important  causes. 

Too  early  development  might  also  be  mentioned  here. 
This  leads  to  menstrual  disorders,  principally  Menorrhagia. 
It  may  also  excite  ovaritis  as  a  result  of  the  repeated  conges- 
tions of  the  ovary,  which  comes  from  too  early  development. 

Reed  mentions  occupation  as  an  important  cause  of  female 
weakness.  He  sa3-s:  "The  modern  extension  of  woman's  activ- 
ity has  brought  with  it  more  or  less  of  a  penalty  in  the  form  of 
genital  diseases  induced  by  it.  It  was  not  to  be  expected  that 
women  could  adjust  themselves  without  damage  to  labours 
w^hich,  through  generations,  had  been  arrangetl  for  men.  Clerk- 
ing in  stores,  with  its  long  hours  of  uninterrupted  standing,  lift- 
ing and  carrying  of  heavy  loads  and  the  performance  of  over- 
head tasks,  which  require  stretching  of  the  body,  are  the  most 
important  examples  which  illustrate  the  influence  of  occupation 
as  a  cause  of  female  diseases." 

CONSTIPATION.  Constipation  is  a  common  cause  or  ac- 
companiment of  female  disease;  the  vast  majority  of  gynecol- 
ogical patients  suffering  from  it.     On  account  of  the  proximity 

6 


82 


DISEASES    OF    WOMEN. 


of  the  rectum  to  the  uterus,  an  accumulation  of  feces  gives  rise 
to  local  trouble,  by  pushing  the  uterus  out  of  its  place.  Hab- 
itual constipation  causes  obstruction  to  the  venous  circu- 
lation of  the  pelvis  and  is  a  cause  of  congestive  hypertrophy  of 


Fig.  3f) — Impacted  bowel  iorcins  the  uterus  Into  sliglit  retroversion. 

the  uterus,  a  varicose  condition  of  the  veins  of  the  rectum  and 
even  a  stagnation  of  the  blood  in  the  vessels  that  lie  between 
the  layers  of  the  broad  ligaments.     The  obstruction  to  the  cir- 


GENERAL    CAUSES    OF    DISEASE.  83 

culation  is  at  first  purely  a  mechanical  one,  but  at  last  the  coats 
of  the  vessels  lose  their  tone,  and,  having  become  habitually 
over-stretched,  are  very  likely  to  remain  in  that  distended  con- 
dition even  after  the  pressure  has  been  removed. 

The  absorption  of  the  gases  and  liquid  parts  of  the  feces 
affects  the  blood,  and  headaches,  neuralgia  and  a  general  tired 
feeling  result.  The  straining  at  stool,  which  is  a  necessary  ac- 
companiment of  constipation,  tends  to  force  the  uterus  and  adnexa 
downward  in  a  state  of  prolapsus.  In  other  cases,  diarrhea  compli- 
cates menstruation;  in  some,  taking  the  place  of  it.  This  shows 
the  close  sympathy  between  the  uterus  and  bowel;  in  fact,  all 
the  pelvic  viscera  are,  in  a  sense,  mutually  dependent. 

DRESS.  A  girl  scarcely  enters  her  teens  before  fashion  and 
custom  require  a  change  in  her  mode  of  dress.  Instead  of  her 
clothes  being  supported  by  shoulder  straps  and  buttons,  the 
skirts  are  held  up  by  a  numbe"  of  strings  and  bands  about  the 
waist.  I  have  counted  on  patients,  as  many  as  ten  different  bands 
encircling  the  waist. 

By  the  wearing  of  corsets,  the  waist  is  drawn  into  a  shape 
little  adapted  to  accommodate  the  organs  of  the  abdominal  and 
pelvic  cavities,  and  as  the  abdominal  and  spinal  muscles  are 
seldom  brought  into  use,  they  become  atrophied.  The  ab- 
dominal viscera  are  compressed  and  displaced  downward  by  the 
tightly  fitted  corset,  -e  action  of  the  diaphragm  interfered  with, 
and  the  venous  return  from  the  uterus  to  the  heart  hindered. 
The  uterus  being  very  vascular,  receives  most  of  this  blood  thus 
obstructed,  with  the  result  that  its  specific  gravity  is  increased 
and  it  is  forced  downward. 

The  wearing  of  small,  tight  bands,  belts  or  strings  around 
the  waist  is  to  be  condemned  as  much  as  the  wearing  of  a  tightly 
fitted  corset.     If  such  bands  are  necessary,  it  is  better  to  wear 


84 


DISEASES    OF   WOMEN. 


a  loose  corset  which  prevents  them  from  sinking  into  the  abdom- 
inal wall,  it  being  the  lesser  of  the  two  evils.  One  writer  says: 
"In  cases  in  which  heavy  skirts,  the  weight  of  which  is  supported 
by  bands,  are  worn,  corsets  should  be  worn.  They  should  be 
stiffer  than  usually  made,  if  they  are  to  effectively  protect  the 
soft  middle  portion  of  the  body  from  pressure  of  the  waist  band. 


Fig.  37 — Showing  enteroptosis  from 
iin   Improperly  wcjrn  corset. 


Fig.  38 — A  properly  fitted  corset. 


The  front  should  be  quite  straight  and  the  waist  measurement 
should  be  at  least  as  large  as  the  wearer's  waist,  measured  over  a 
single  garment." 

The  ribs  are  forced  downward  until  they,  in  some  cases, 
TOUCH  THE  CREST  OP  THE   ILIUM.     This  forces   the  diaphragm 


GENERAL   CAUSES   OF   DISEASE. 


85 


downward  also,  since  it  is  attached  to  the  lower  ribs.  The  erec- 
tor muscles  of  the  back  are  weakened,  on  account  of  the  body- 
being  supported  by  artificial  means.     Degeneration  and  atrophy 

of  these  spinal  muscles  follow 
as  a  natural  sequel,  and  the  pa- 
tient feels  weak  and  exhausted 
without  her  corset. 

Deficiency  of  dress  of  the 
neck,  shoulders,  arms  and  legs 
is  conducive  to  internal  en- 
gorgements, which  are  followed 
by  pathological  congestion. 
These  are  accompanied  b  y 
leucorrhea,  menstrual  disorders, 
local  and  reflex  pains,  and  pos- 
sibly uterine  displacements  from 
increased  weight. 

How  common  a  thing  it  is  for 
a  young  lady  to  attend  some 
function  in  the  evening,  dressed 
in  garments  entirely  different  in 
character  and  warmth  from  those 
to  which  she  has  been  accustomed.  The  most  pernicious  costume 
is  the  decollete.  Internal  congestions  particularly  follow, 
since  the  peripheral  vessels  contract  from  the  effect  of  the 
thermic  influences. 

If,  at  the  age  of  puberty,  while  all  articulations  are  subject 
to  change,  high  heeled  shoes  are  worn,  not  only  the  shape  of  the 
feet  is  altered,  but  the  inclination  of  the  pelvis  is  changed  and 
the  normal  curvature  of  the  back  deranged;  a  kyphosis  of  the 
lumbar  region  resulting.  The  immediate  effect  is  that  of  back- 
cahe  from  the  strain  thrown  on  the  spine. 


Fig  39 — Showing  the  injurious  effect 
of  pressure  on  the  uterus  by  corset 
steels  when  the  patient  bends  forward. 


86  DISEASES    OF    WOMEN. 

STERILITY  AND  ABORTION.  The  function  of  the  female 
pelvic  organs  is  that  of  procreation  and  if  this  is  interfered  with 
or  not  performed,  it  constitutes  an  unnatural  state,  thus  form- 
ing an  important  cause  of  female  disease.  Most  forms  of  fibroid 
tumors  of  the  uterus  are  more  common  in  the  unmarried  than  in 
those  who  have  borne  children,  and  still  more  common  in  the 
sterile  than  in  any  other  class.  One  explanation  is  that  the 
REPEATED  MENSTRUAL  CONGESTION  and  ovarian  hyperemia 
caused  by  sexual  excitement,  especially  ungratified  desires,  cause 
a  deposit  or  produce  an  irritation  from  which  the  tumor  forms. 
In  cases  of  dysmenorrhea,  the  physician  frequently  advises 
marriage  as  a  cure;  this  is  in  most  cases  a  confession  that  he  is 
unable  to  cure  the  case.  Marriage,  when  there  is  an  existing 
uterine  disease,  is  usually  contraindicated,  it  only  aggravating 
the  disease,  but  in  some  cases  of  anteflexion  or  imperfect  devel- 
opment of  the  uterus,  it  is  to  be  recommended.  In  many  cases 
the  condition  is  made  worse  by  marriage,  if  the  laws  of  health 
and  nature  are  ruthlessly  and  repeatedly  broken. 

The  practice  of  preventing  conception  is  as  old  as  his- 
tory. Many  methods  are  in  vogue,  such  as  the  use  of  vaginal 
douches,  astringents  applied  to  the  mouth  of  the  womb,  the  use 
of  a  sponge  to  absorb  the  semen,  womb  caps,  condoms  and 
other  devices,  all  of  which  have  a  more  or  less  deleterious  effect 
on  the  health  of  the  individual.  Although  the  local  effect  is  not 
at  first  very  marked,  the  psychic,  as  well  as  the  general  effect, 
becomes  very  great  after  a  while.  When  practiced  very  long, 
the  patient  becomes  thin,  nervous,  has  leucorrhea  and  feels  "all 
run  down."  This  is  in  fact  the  condition.  Progressive  emacia- 
tion is  a  common  sequel.  If  pregnancy  should  accidentally  take 
place  and  the  fetus  is  carried  to  term,  the  offspring  are  affected  by 
being  handicapped  by  a  weak  constitution,  a  bad  disposition 


GENERAL    CAUSES    OF    DISEAE. 


87 


and  possibly  a  perverted  sexual  organism.  In  a  large  per  cent, 
of  cases,  abortion,  miscarriage  or  premature  labor  results. 

Recently  there  was  an  editorial  in  one  of  the  leading  med^ 
ical  journals  in  which  it  was  stated  that  "in  the  fashionable  fiats- 
(ref erring  to  New  York  City)  a  dog  is  more  welcome  than  a 
BABY."  This  is  undoubtedly  true  and  depicts  a  deplorable  state-- 
of  affairs.  The  nation's  future  is  imperiled  by  such  things.  Evere 
now  the  bulk  of  the  children  are  found  in  the  poor  man's  home, 
while  those  who  are  capable  of  properly  rearing  and  educating 
them,  are  childless. 

Criminal  abortion  is  one  of  the  very  important  causes  of 
female  diseases.  Its  prevalence  is  astonishing.  Rigid  laws  have 
been  enacted  against  the  practice,  yet  every  city  has  its  pro- 
fessional abortionists,  or  its  physicians,  at  least  some  one  of 
them,  are  in  communication  with  such  and  get  a  per  cent,  of  the 
income  from  all  patients  sent. 

The  local  effects  are  subinvolution,  displacement,  leucor- 
rhea,  menstrual  disorders,  especially  flooding  and  irregularity, 
the  various  reflex  aches  and  general  debility.  The  after,  and 
general  effects  are  nervousness,  aches  of  various  kinds,  and 
mental  depression. 

LESIONS.  From  an  osteopathic  standpoint,  the  lesions 
which  are  found  along  the  spinal  column  and  pelvic  bones  are 
the  most  important  of  the  predisposing,  as  well  as  exciting,  causes 
of  female  diseases. 

By  lesion  is  meant,  if  applied  to  a  bone,  a  partial  displace- 
ment   OF   THE    BONE,   ACCOMPANIED    BY    SOME    DISTURBANCE  SUCH 

AS  IRREGULARITY  and  TENDERNESS.  Irregularity  alone  does  not 
constitute  a  lesion,  but  irregularity  with  tenderness  or  disturb- 
ance of  the  function  of  the  joint  or  viscus  innervated  by  the 
nerve  in  relation  with  the  joint,  constitutes  a  lesion. 


88 


DISEASES    OF    WOMEN. 


Fig.  4()-Po.storior  curvature  of  lumbar  region.  (I->oni  photo  of  author's  case.) 


GENERAL    CAUSES    OF    DISEASE.  89 

A  lesion  of  the  lower  dorsal  vertebrae  (the  10th,  11th  and 
12th)  may  cause  pelvic  disease  by  affecting  the  deep  origin  of 
the  piidic,  sciatic,  or  in  fact  all  the  lumbar  and  the  majority  of 
the  sacral  nerves.  The  segments  of  the  cord  from  which  the 
pudic  nerve  arises,  are  on  a  level  with  the  r2th  dorsal  and  1st 
lumbar  vertebrae.  The  spinal  cord  terminates  at  the  upper 
border  of  the  second  lumbar  vertebra.  The  origin  of  all  the 
sacral  and  lumbar  ner\'es  must  be  above  this  point,  thus  a  lesion 
above  this  point,  that  is  in  the  lower  dorsal  region,  may  affect 
the  nerves  going  to  the  uterus,  ovaries,  rectum,  etc.  Then  arises 
the  question  how  a  lesion,  or  what  we  call  a  subluxation  of  the 
vertebra,  or  curvature  would  affect  the  deep  or  high  origin  of 
these  nerves.  First,  the  bone  may  cause  a  direct  pressure  on 
the  nerve  trunk,  but  in  such  cases  there  is  usually  a  complete 
displacement  of  the  vertebra  coupled  with  paralysis,  which  con- 
dition is  rare  compared  with  the  partial  displacements.  A  better 
explanation  is  that  the  ganglia  on  the  posterior  nerve  roots 
which  are  in  the  foramina,  are  impinged  upon,  by  the  articular 
processes,  they  being  in  direct  relation.  Also  the  blood  sup- 
ply to  the  nerve  cells  is,  in  a  like  manner,  affected,  hence  the 
chronic  disturbances,  without  complete  paralysis,  which  would 
follow  continued  pressure  on  a  nerve.  Second,  it  may  affect 
the  nutrition  of  the  cord  or  the  blood  supply  to  a  segment  of 
the  cord.  The  blood  is  returned  by  veins  which  empty  into  the 
intercostal  and  lumbar  veins,  which  also  drain  the  muscles  of 
the  back  in  that  region.  A  subluxation  of  the  vertebra,  how- 
ever slight,  vdW  affect  the  blood  stream  and  a  disturbance  must 
follow.  A  contracture  of  the  back  muscles,  causes  a  stagnation 
of  the  blood  in  the  muscles  and  from  this  follows  a  venous  conges- 
tion of  the  corresponding  part  of  the  spinal  cord. 

The  nerves  usually  affected  are  the  pudic,  sacral  and  the 


90  DISEASES    OF   WOMEN. 

rami  communicantes.  In  the  case  of  the  pudic  nerve,  a  lesion 
at  the  lower  dorsal  may  cause  inhibition  or  stimvdation,  that  is 
a  loss  of  sexual  vigor  or  increased  passion,  or  nymphomania. 
The  pudic  nerve  innervates  almost  the  entire  pelvic  floor.  The 
TONICITY  of  the  floor  to  a  great  degree  depends  on  the  integrity 
and  healthy  action  of  this  nerve.  The  position  of  the  uterus 
depends  to  a  marked  extent  upon  the  amount  of  tone  in  the  pel- 
vic floor.  From  the  above  a  conclusion  can  be  drawn  in  refer- 
ence to  the  relation  of  the  pudic  nerve  to  the  pelvic  floor  and 
uterine  lesions. 

An  interference  with  the  sacral  nerves  also  causes  a  dis- 
turbance of  the  pelvic  floor,  uterus  and  rectum,  since  the  dis- 
tribution of  these  nerves  is  to  these  parts.  The  rami  commu- 
nicantes, are  also  impinged  upon  by  a  luxated  vertebra,  which 
if  in  the  lower  thoracic  region,  produces  a  disturbance  of  the  lesser 
and  least  splanchnics.  A  disturbance  of  the  least  splanchnic 
causes  a  change  in  the  renal  plexus.  From  this  plexus  is  derived 
the  ovarian  plexus,  thus  ovarian  trouble  and  uterine  disease 
may  follow  as  a  result  of  such  a  lesion. 

A  subluxation  of  the  11th  or  12th  rib,  and  by  the  way  such 
a  lesion  is  common,  may  affect  the  gangliated  cord,  or  as  in  the 
case  of  vertebral  lesions,  the  rami,  which  send  branches  to  the 
renal  plexus  from  which  is  derived,  in  part,  the  ovarian  plexus. 
The  gangliated  cord  is  very  near  to,  while  the  rami  cross  the 

HEADS   of   the    ribs,  AND    HOWEVER    SLIGHT   THE    RIB    LESION     the 

nerve  will  be  affected  thereby. 

As  to  the  way  the  nerves  are  affected,  it  depends  on  the  dis- 
placed bone  whether  it  presses  directly  or  indirectly  on  the  nerves 
or  blood  vessels.  There  may  be  paralysis,  pain,  or  simply  an 
impairment  of  the  function.  The  most  common  sequelae  of  these 
lesions    are,    ovarian    colic,    inflammation,    atrophy    or  enlarge- 


Fjg.  41— Anterior  curvature  of  thoracic  regi'Mi.  (From  i)liot()  of  autlior's  case). 


92  DISEASES    OF    WOMEN. 

ment  of  the  ovary.  These  diseased  conditions  of  the  ovar}'  re- 
sult in  painful  menstruation,  amenorrhea  or  menorrhagia.  The 
effect  on  the  diaphragm  and  its  relations  to  the  pelvic  organs 
might  be  discussed,  but  I  will  only  mention  the  fact  that  when 
these  ribs  are  displaced  the  position  of  the  diaphragm  is  changed 
and  the  return  flow  of  blood  affected. 

A  lesion  of  the  lumbar  vertebrae  may  affect  the  gangliated 
cord  which  lies  on  the  bodies  of  the  vertebrae; it  may  affect  the 
RAMI  commuxicantes  or  the  lumbar  nerves  which  go  to  make 
up  the  lumbar  plexus  and  the  lumbo-sacral  cord.  The  lumbar 
gangliated  cord  sends  branches  to  the  aortic  and  inferior 
mesenteric  plexuses,  also  to  the  inferior  vena  cava.  The 
ovarian,  derived  from  the  aortic,  and  renal,  supplies  the  ovaries, 
tubes  and  uterus.  The  inferior  mesenteric,  sends  branches  to 
the  left  or  descending  colon,  the  sigmoid  colon  and  the  rectum, 
on  which  accotmt  a  lesion  of  the  lumbar  vertebrae  may  produce 
ovarian,  tubal ,  uterine  or  bowel  trouble.  It  is  a  well  known  fact 
that  constipation  often  complicates  uterine  disease.  One  reason 
is  that  the  nerve  supply  is  practically  from  the  same  source  and 
a  lesion  of  the  lumbar  vertebrae  will  produce  both. 

Dr.  Still  once  remarked  to  me  that  young  girls  in  school, 
in  bending  over  desks  and  sitting  in  that  position  for  several 
hours  every  day,  are  often  affected  with  a  condition  of  kyphosis 
which  weakens  the  pelvic  organs,  bringing  on  backache,  men- 
strual irregularities  fnd  leucorrhea,  since,  from  the  changed  re- 
lation of  the  lumbar  vertebrae,  the  above  mentioned  nerves  are 
affected. 

The  hypogastric  plexus  is  located  on  the  promontory  of  the 
sacrum,  hence  a  lesion  of  the  5th  lumbar  will  usually  affect  this 
plexus,  and  from  this  pelvic  disorders  arise. 

The  centers  for  the  uterus,  especially  for  the  longitudinal 


GENERAL    CAUSES    OF    DISEASE. 


93 


Fig.  42 — SiiiUfjlit  spine.  (.Froui  photo  of  author's  case). 


94  DISEASES    OF    WOMEN. 

fibers,  are  located  in  the  lumbar  enlargement  of  the  cord.  These 
centers  may  be  affected  by  a  lesion  of  the  upper  lumbar  verte- 
brae. The  effect  is  usually  one  of  weakening  of  the  expulsive 
forces  of  the  uterus,  hence  menstrual  disturbances,  such  as  cramp- 
ing, follow. 

The  above  principle  is  exemplified  in  after-pains  in  labor 
cases;  they  being  due  to  insufficient  contraction  of  the  longi- 
tudinal muscle  fibers. 

A  lesion  at  the  1st  and  2nd  lumbar  vertebrae  might  affect 
the  iLio-iNGUiNAL  and  genito-crural  nerves,  since  they  make 
their  exit  at  the  1st  and  2nd  lumbar  foramina.  This  would  re- 
sult in  pain  in  the  iliac  fossae,  loss  of  tone  in  the  abdominal  mus- 
cles and  round  ligaments,  as  the  ilio-inguinal  and  ilio-hypogas- 
tric  supply  the  abdominal  wall,  and  the  genito-crural  the  round 
ligaments.  From  a  weakening  of  these  structures  comes  a  weak- 
ening of  the  supports  of  the  uterus,  and  with  this  a  tendency  to 
displacements,  especially  retro- deviation  and  prolapsus. 

The  lesions  of  the  sacrum,  while  often  overlooked  and  their 
importance  underestimated,  are,  notwithstanding,  important 
factors  in  connection  with  pelvic  diseases.  The  sacrum  supports 
the  weight  of  the  body.  Through  it  every  jar  is  communicated 
to  the  spinal  column  which  is  supported  by  it,  and  on  account  of 
its  position,  being  wedged  in  between  the  two  innominate  bones, 
it  is  subject  to  a  great  deal  of  strain.  On  account  of  its  obliquity 
it  is  subject  to  displacements  of  various  degrees;  the  most  coin- 
mon  of  these  is  a  rotation,  the  upper  part  being  thrown  forward 
and  downward,  the  lower  part  backward  and  upward. 

The  structures  lying  in  relation  with  the  sacrum  are  the 
ROOTS  OF  the  sacral  PLEXUS  with  most  of  its  branches,  the 
hypogastric  plexus  with  its  immediate  connection,  and  certain 
ligaments,  the   most  important  of  which    are  the    utero-sacral 


GENERAL    CAUSES    OF    DISEASE.  95 

ligaments.  These  roots  forming  the  sacral  plexus,  lie  in  rela- 
tion with  and  are  bound  down  to  the  sacro-iliae  articulation, 
hence  the  uterine  diseases  and  the  various  disturbances  of  the 
sciatic  nerve  which  follow  a  twist  or  subluxation  of  either  the 
sacrum  or  innominate. 

The  UTERO-SACRAL  LIGAMENTS  have  to  do  with  holding  the 
lower  part  of  the  uterus  in  position,  and  are  placed  in  an  oblique 
almost  vertica^  position,  when  the  patient  is  erect.  Disturbances 
of  the  uterus  as  to  its  position  follow,  when  these  ligaments  are 
abnormally  relaxed  or  put  on  a  tension  as  they  would  necessarily 
be  in  abnormal  positions  of  the  sacrum. 

Of  all  the  bony  lesions  associated  with  pelvic  disease,  a  dis- 
located INNOMINATE  is  the  most  common.  Whether  the  case 
be  one  of  menorrhagia  or  metritis,  the  innominates  should  be  ex- 
amined for  some  deviation  from  normal.  This  deviation  is  usually 
a  backward  slip  as  is  evidenced  by  irregularity  and  prominence  of 
the  posterior  spines  of  the  ilium  and  tenderness  at  the  synchon- 
drosis. The  length  of  the  limb  is  usually  shortened  if  only  a 
rotation  is  present,  but  since  some  other  displacement  often 
accompanies  a  rotation,  the  length  of  the  limb  is  not  a  very 
reliable  indidation  by  which  to  diagnose  the  character  of  the 
innominate  lesion.  However,  the  question  before  us  is 'how  does  a 
slipped  innominate  cause  pelvic  disease?" 

The  ROOTS  OF  THE  SACRAL  plexus,  as  stated  before,  are  in 
relation  with  and  are  bound  to  the  ilio-sacral  articulation, 
hence  any  deviation  at  this  point,  however  slight,  will  affect 
the  sacral  nerves.  It  is  a  well  known  fact  that  sciatica  and 
other  limb  troubles,  are  often  associated  with  pelvic  diseases. 
This  is  explained  by  the  above.  The  sacral  nerves  are  especially 
distributed  to  the  cervix  and  are  important  factors  in  expulsion 
of  the  contents  of  the  uterus.     By  an  irritation  of  these  nerves, 


96  DISEASES    OF   WOMEN. 

the  OS  is  constricted  and  menstruation  made  painful.  By  an 
INHIBITION,  the  OS  remains  patulous  and  menorrhagia  is  often 
found.     This  lesion  often  destroys  the  harmony  existing 

BETWEEN     THE     CEREBRO-SPINAL     AND      SYMPATHETIC     SYSTEMS. 

Whether  expulsion  is  interfered  with  by  an  obstruction,  or  by 
an  insufficient  contraction  of  the  longitudinal  muscle  fibers, 
THE  RHYTHM  IS  DESTROYED  and  disturbance  of  function  follows. 
To  me  this  is  a  very  important  point.  Again,  the  intimate  connec- 
tion existing  between  the  sacral  plexus  and  the  sympathetic  gang- 
liated  cord  will  also  help  in  explaining  the  relation  between  the 
cause  and  effect.  The  white  rami,  and  some  say  the  gray,  con- 
nect the  roots  of  the  sacral  plexus  with  the  sympathetic  chain; 
this  chain  also  gives  off  branches  which  go  direct  to  the  inferior 
hypogastric  plexus,  thus  there  is  a  direct  connection  be  ween 
the  two. 

By  a  subluxation  of  the  innominate  bone,  certain  muscles, 
especially  the  iliacus  and  levator  ani,  would  be  put  on  a  tension 
or  relaxed  and,  since  they  are  in  relation  with  the  pelvic  struc- 
tures, derangements  would  follow.  The  broad  ligaments  are 
attached  to  the  sides  of  the  innominate  bones.  On  account  of 
their  connection  with  the  uterus  and  the  relation  to  the  vessels 
and  nerves  which  supply  it,  a  twisting,  increased  tension  or  re- 
laxation, will  materially  affect  the  amount  of  blood  passing  to 
and  from  the  uterus.  The  displacement  of  the  innominate  bones 
will  AFFECT  ALL  TISSUES  attached  to  them;  this  will  in  turn  affect 
all  neighboring  structures  and  organs.  On  this  account  the 
puDic  NERVE  is  liable  to  be  affected,  at  or  near  the  place  at  which 
it  crosses  the  spine  of  the  ischium. 

A  displacement  of  the  coccyx  often  causes  disease  by  putting 
muscles  on  a  strain,  by  affecting  the  ganglion  impar,  or  by 
pressure    on    neighboring    structures    or    organs.     Hemorrhoids 


GENERAL    CAUSES    OF    DISEASE,  97 

often  result  from  a  displaced  coccyx.  Pruritus  ani  or  itching 
piles  are  often  found.  In  such  cases  there  are  often  found  sexual 
derangements,  the  most  common  of  which  is  a  form  of  nympho- 
mania. 

Our  conclusion  is  that  very  particular  attention  should 
be  paid  the  bony  framework,  since  a  derangement  of  it  forms  the 
basis  of  nearly  all  female  diseases,  especially  the  chronic  types. 
One  of  the  fundamental  principles  of  osteopathy  is  based  on  the 
condition  of  the  framework  of  the  human  body,  and  constitutes 
the  point  of  greatest  difference  between  it  and  the  various  pathies. 

If  any  of  these  lesions  mentioned  are  found  in  a  case  of  in- 
flammation of  the  uterus,  all  the  topical  applications  known 
will  not  cure,  although  they  may  temporarily  relieve,  until  the 
abnormality  is  corrected.  The  exciting  causes  of  uterine  dis- 
eases act  with  difficulty  if  the  bony  framework  is  perfectly  ad- 
justed. The  secretions  will  be  normal,  the  circulation  good, 
the  lymphatics  will  act  properly  and  the  position  of  the  uterus 
will  not  become  pathological.  The  old  dictum  that  the  blood 
IS  THE  LIFE  is  of  more  importance  to  the  osteopath  than  to  any 
other  class  of  practitioners.  The  blood  is  both  food  and  air  to 
the  tissues,  and  also  acts  as  a  scavenger.  It  carries  nutrition  and 
takes  away  the  deleterious  products.  The  blood,  to  fulfil  its 
function  or  purpose,  must  be  moving.  It  cannot  carry  nutri- 
tion or  TAKE  AWAY  delctenous  products  if  it  does  not  move, 
and  that  quite  rapidly. 

There  are  several  factors  or  forces  besides  that  of  the  heart 
concerned  in  the  propulsion  of  the  blood  through  its  circuit. 
Pressure,  exerted  by  contraction  of  organs  or  tissues,  forces 
the  blood  into  the  veins  and  the  arterial  blood  rushes  in  to  fill 
the  vessels  thus  emptied.  The  veins,  having  valves,  allow  the 
blood  to  be  forced  in  only  one  direction,  that  is  toward  the  heart. 


98  DISEASES   OF   WOMEN. 

This  pressure,  to  be  effective,  must  be  intermittent.  Standing 
on  the  feet,  in  which  the  pressure  is  constant,  produces  fatigue. 
Fatigue  is  due  to  impoverished  blood;  impoverished  blood  is 
due  to  a  stoppage  or  lessening  of  rapidity  of  blood  current 
in  some  part  of  the  body.  In  ordinary  fatigue  from  muscular 
exercise,  the  stoppage  is  in  the  veins  of  the  muscles.  Ek 
ercise,  if  not  excessively  indulged  in,  by  which  the  muscles  con- 
tract intermittently,  is  an  aid  to  the  circulation. 

Bony  lesions  produce  contracture  or  relaxation  of 
muscles.  Either  disturbs  the  function  and  destroys  the  inter- 
mittent pressure  which,  as  stated  above,  Ls  of  assistance  in  the 
•circulation  of  the  blood.  This  furnishes  another  reason  why 
lesions  produce  disease. 

It  might  be  mentioned  in  this  connection  that  respiration, 
which  is  the  result  of  a  rhythmical  contraction  of  the  muscles  con- 
cerned in  the  respiratory  function,  exerts  a  wonderful  influence 
on  the  pelvic  circulation.  Deep  rhythmical  breathing  tends  to 
force  the  blood  more  rapidly  through  the  uterus  than  shallow, 
irregular  respiration.  In  fact,  the  latter  results  in  uterine  con- 
gestion and  is  the  cause  in  some  cases,  of  the  uterine  disease. 
In  summing  up  the  various  causes  of  female  disease  we  are  forced 
to  the  conclusion  that  a  perfect  circulation  through  the  pel- 
vic viscera  is  necessary  to  the  perfect  functioning  of  those 
parts,  and  that  any  lesion  or  other  pathological  condi- 
tion interfering  with  this,  predisposes  to  disease  of  the  pelvic 
viscera.  If  the  blood  is  pure  and  circulates  normally  through 
the  uterus,  there  is  little  or  no  danger  of  it  becoming  diseased. 

EXCITING  CAUSES.  Childbirth  is  one  of  the  most  important 
of  the  exciting  causes  of  disease,  especialh^  if  laceration  has 
taken  place  and  has  not  healed.  Tears  of  the  vagina  or  peri- 
neum lay  the  foundation  •for'prolapsus  of  both  vagina  and  uterus. 


GENERAL    CAUSES    OF    DISEASE  99 

Laceration  of  the  perineal  body  weakens  the  keystone  of  the 
pelvic  floor,  impairing  its  function  to  such  a  degree  that  it  is  im- 
possible for  the  two  vaginal  walls  to  be  held  in  apposition.  This 
is  made  the  more  likely  on  account  of  the  increased  size  of  the 
fetal  head  from  civilization  and  education. 

Laceration  of  the  cervix,  which  is  usually  the  result  of 
administration  of  ergot  or  quinine  causing  too  rapid  delivery, 
prevents  proper  involution  after  delivery.  From  this  follows  a 
CONGESTIVE  HYPERTROPHY  accompanied  by  a  hypersecretion  or 
leucorrhea,  also  displacements  with  their  accompanying  aches 
and  reflex  pains.  I  am  glad  to  say  that  the  osteopath,  in  or- 
dinary    CASES,     prevents    THESE     LACERATIONS      FROM      TAKING 

place,  thereby  preventing  an  inestimable  amount  of  disease. 
Many  cases  of  neurasthenia  and  hysteria  result  from  a  lacerated 
cervix,  which  has  not  healed  and  keeps  the  parts  irritated,  causing 
a  constant  loss  of  nerve  force. 

It  is  sufficient  at  present  to  call  attention  to  the  fact  that 
the  cervix  is  covered  with  erectile  tissue  and  is  therefore  sup- 
plied with  a  great  many  blood  vessels,  which  are  enclosed  in  a 
network     of  nerves  from  the  sympathetic  system. 

Too  early  rising  after  confinement,  before  the  uterus  has 
contracted  sufficiently  often  causes  enlargement  and  displace- 
ment of  the  organ.  Again,  if  the  patient  remains  in  the  dorsal 
position  too  long  after  confinement,  retroversion  will  usually 
result,  all  of  which  tend  to  increase  the  amount  of  blood  in  the 
uterus.     This  in  turn,  affects  the  nerves  in  relation. 

Labor  predisposes  to  female  disease,  in  that  lesions,  especi- 
ally of  the  spine  and  pelvis  often  result  from  it.  The  position 
of  the  patient,  the  fearful  straining,  especially  in  hard  cases,  all 
TEND  to  displace  the  vertebrae,  innominata,  hips,  sacrum  or 
coccyx.     This  results    in  a  weakening  of  the  pelvic  viscera,  as 


100  DISEASES   OF   WOMEN. 

previously  noted.  Such  lesions,  especially  of  the  innominate 
bones,  occur  quite  easily  on  account  of  the  increased  mobility 
of  the  sacro-iliac  synchrondrosis  during  pregnancy,  the  patient 
often  complaining  of  a  "catch"  in  the  hip,  sometimes  severe 
enough  to  cause  her  to  fall.  This  is  due  to  a  slight  slip  in  the 
sacro-iliac  joint.  Milk  leg  is  the  occasional  sequel  of  such  a 
lesion,  and  in  many  cases  the  hip  is  also  involved. 

A  PENDULOUS  ABDOMEN  is  a  commou  sequel  to  labor  and 
predisposes  to  pelvic  disease  by  producing  enteroptosis,  which 
condition  interferes  with  the  normal  circulation  through  the 
pelvic  viscera.  The  intestines  are  forced  into  the  pelvis  and 
congestion,  with  its  so-called  catarrh  or  leucorrhea  is  a  common 
effect. 

Occasionally  an  ovary  is  caught  between  the  fetal  head 
and  the  brim  of  the  pelvis  and  there  bruised  or  lacerated.  An 
ovarian  abscess  often  follows  such  an  injury;  at  least  ovaritis  is 
produced. 

The  proper  care  of  labor  cases  will  prevent  a  great  many 
female  disorders.  Prophylaxis  is  even  of  greater  importance 
than  curative  measures  that  are  not  applied  until  after  the  dis- 
ease is  under  headway. 

GYNECOLOGICAL  TREATMENT.  The  practice  of  intro- 
ducing an  instrument  into  the  uterine  cavity  to  correct  a  dis- 
placement is  sometimes  the  cause  of  inflammatory  conditions 
of  the  uterus.  The  endometrium  is  a  very  delicate  membrane 
and  although  a  dull  sound  is  used,  the  chances  are  that  this  mem- 
brane will  be  injured.  The  practice  of  curetting  the  uterus,  as 
is  ordinarily  performed  by  the  regular  physician,  is  to  be  more 
severely  condemned.  Unless  polypi  or  cancerous  growths  are 
present,  curetting  is  contraindicated,  because  it  leaves  a  raw, 
bleeding  surface  which  results  in  inflammation  or  perhaps  in- 


GENERAL   CAUSES   OF   DISEASE.  101 

fection  and  even  in  the  above  mentioned  cases  is  rarely  indicated. 

All  intra-uterine  treatments  with  sounds,  curettes,  tents, 
dilators  and  pessaries  are  fraught  with  danger  on  account  of  the 
absorptive  qualities  of  the  uterine  lymphatics.  Neariy  all  intra- 
vaginal  treatments  in  which  instruments  are  used,  are  injurious. 
I  have  examined  cases  in  which  pessaries  were  found  embedded 
in  the  tissues  of  the  vagina,  having  been  there  several  months. 
The  practice  of  using  pessaries  irritates  the  mucous  membrane 
and  keeps  it  inflamed,  preventing  nature  from  healing  the  part. 

Douches,  if  indulged  in  for  any  length  of  time,  are  the  cause 
of  disease.  The  author  has  noted  case  after  case  in  which 
douches  had  been  used  and  in  every  one,  found  the  fomices  dis- 
tended, thus  forming  quite  a  cavity  around  the  cervix.  This 
induces  uterine  displacement,  particularly  retroversion  and 
prolapsus.  Caustics  applied  to  the  cervix  in  the  treatment  of 
certain  forms  of  disease  are  injurious  and  tend  to  prolong  the 
existing  disease.  Astringents  have  also  been  advised  but  their 
use  is  not  indicated  except  in  severe  cases  of  metrorrhagia.  Such 
applications  used  for  any  length  of  time  destroy  the  function  of 
the  mucous  glands  lining  the  vagina.  As  a  result  the  walls  be- 
come dry,  and  become  covered  with  wrinkles  or  folds.  A  local 
digital  examination  is  hard  to  make  in  such  cases  and  the  sexual 
function  is  impaired,  or  more  often,  destroyed.  In  other  cases 
the  condition  of  the  mucous  membrane  of  the  vagina  is  a  very 
reliable  index  to  the  condition  of  the  sexual  organs.  Frequent 
LOCAL  treatment  as  ordinarily  practiced  is  an  exciting  cause  of 
disease.  They  should  not  be  given  more  often  than  once  a  week, 
except  in  very  unusual  cases.  Often  the  nervous  shock  counter- 
acts the  good  they  do. 

GONORRHEA.  Latent  or  chronic  gonorrhea  is  a  cause 
of  many  of  the  various  forms  of  uterine,  tubal  and  ovarian  dis 


102  DISEASES   OF   WOMEN. 

ease,  especially  of  the  inflammatory  and  suppurative  types.  The 
inflammation  extends  from  the  vagina  through  the  uterus  to  the 
Fallopian  tubes,  peritoneal  cavity  and  ovaries.  This  results 
in  a  chronic  type  of  inflammation  characterized  by  the  formation 
of  adhesions.  It  manifests  itself  by  a  general  weakness,  back- 
ache, leucorrhea,  sterility,  chronic  soreness  over  the  tubes  and 
ovaries, the  result  of  the  chronic  inflammation,  and  by  discharge 
OF  pus  in  the  more  pronounced  cases.  Byron  Robinson  states 
that  "gonorrhea  is  the  essential  element  in  a  vast  majority  of 
intra-pelvic  suppuration."  This  is  true  of  most  chronic  dis- 
charges. He  also  states  that  "the  disease  (referring  to  latent 
gonorrhea)  is  incurable;"  that  the  "acquired  gonococcus  is  never 
wholly  eradicated  from  the  pockets,  recesses  and  folds  of  the 
genito-urinary  tract,  that  the  gonorrheal  germ  simply  repro- 
duces itself  in  undisturbed  locations."  Perhaps  the  above  is 
an  exaggeration,  yet  the  frequency  of  such  conditions  is  astonish- 
ing. The  author  regards  it  of  so  much  importance  that  a  micro- 
scopical EXAMINATION  is  advised  in  all  cases  of  chronic  discharge 
from  the  genitalia,  especially  if  the  case  does  not  readily  respond 
to  the  ordinary  treatment.  In  some,  the  discharge  is  so  strongly 
acid  that  the  gonococci  are  hard  to  recognize  on  account  of  dis- 
integration. In  such  cases  repeated  examinations  are  necessary. 
In  doubtful  cases  an  examination  of  the  husband  will  clear  up  the 
diagnosis.  The  indications  of  latent  gonorrhea  in  the  husband 
are:  an  occasional  mucous  discharge,  disturbances  of  micturi- 
tion, prostatitis,  tenderness  along  the  posterior  urethra  and  his- 
tory of  an  attack  of  specific  urethritis  some  years  prior.  If  the 
urethritis  once  passes  beyond  the  triangular  ligament  into  the 
prostatic  and  membraneous  portions  of  the  urethra,  a  complete 
cure  is  almost  impossible  and  many  a  case  of  ovarian,  tubal  and 
uterine  disease  is  caused  by  such. 


GENERAL   CAUSES   OF   DISEASE.  103"- 

EXPOSURE  DURING  MENSTRUATION  is  a  very  commoiL 
exciting  cause  of  uterine  disease.  This  occurs  very  frequently 
in  society  people,  they  refusing  to  give  up  the  pleasure  of  the  ball 
room  even  for  a  few  nights  during  the  month.  I  have  seen  many 
cases  of  menstrual  disorders  which  could  be  traced  back  ta 
dancing  during  the  menstrual  period;  getting  warm  and  cool- 
ing off  too  suddenly.  I  have  known  of  many  cases  in  which  the 
patient  sat  in  a  cold  class  room  when  she  was  menstruating,  and 
as  a  result  the  flow  stopped,  inflammation  of  the  uterus  develop- 
ed and  the  patient  was  confined  to  her  bed  for  weeks.  The  ces- 
sation of  the  flow  from  exposure  is  often  the  starting  point  of 
various  female  disorders,  such  as  vicarious  menstruation,  dys- 
menorrhea, amenorrhea,  flooding  at  the  monthly  periods,  and 
all  forms  of  inflammatory  disturbances  of  the  pelvic  peritoneum 
and  the  internal  generative  organs,  especially  acute  inflamma- 
tion of  the  uterus.  Special  care  then  should  be  taken  of  one's 
self  at  this  time  because  exposure  usually  results  in  the  stopping 
of  the  flow,  which  is  detrimental  to  the  organism  by  causing, 
not  only  local  inflammations,  but  systemic  diseases  from  reten- 
tion of  the  discharge. 

The  old  Mosaic  law  that  a  menstruating  woman  should  be 
put  apart  seven  days,  (that  is,  rest  that  length  of  time)  is  a  good 
one,  and  if  it  were  followed  a  little  more  closely  at  the  present 
time,  much  suffering  could  be  avoided  since  any  exposure  or 
overwork  at  one  period,  causes  a  disturbance  of  the  next. 

TRAUMATISM.  The  osteopath  traces  a  great  many 
troubles  to  falls,  strains  and  injuries  of  the  back.  A  fall 
BACKWARD,  if  the  bladder  is  distended,  usually  results  in  a  re- 
tro-displacement of  the  uterus,  especially  if  the  ligaments  are 
weak.  Unless  this  is  corrected  within  a  short  time,  the  patient 
becomes  a  chronic  invalid,  or  at  least  has  chronic  uterine  trouble. 


104  DISEASES    OF   WOMEN. 

Lifting  a  heavy  weight  will  often  strain  the  lower  part  of  the 
back,  which  causes  a  subluxation  of  the  vertebrae  in  relation, 
thus  impairing  the  nerve  supply  to  and  from  the  uterus.  This, 
like  the  above,  usually  causes  uterine  displacements  by  the  sud- 
den change  or  increase  of  intra-abdominal  pressure.  Reaching 
upward,  while  in  a  strained  position,  or  the  carrying  of  platters, 
as  do  waitresses  in  hotels,  is  a  common  exciting  cause  of  female 
disease;  the  ovaries  and  tubes  being  most  frequently  affected. 


METHOD    OF    EXAMINATION,  105 


METHOD  OF  EXAMINATION. 


SUBJECTIVE  EXAMINATION.  When  a  jjatient  comes  into 
your  private  office  for  examination,  there  thould  be  some  sys- 
tem OR  regularity  followed  in  the  examination,  otherwise 
some  important  points  may  be  overlooked.  In  the  examina- 
tion there  should  be  regard  for  the  patient's  feelings,  and  it 
ought  to  be  restricted  to  that  which  is  absolutely  necessary. 

In  the  first  place  a  number  of  points  should  be  ascertained; 
the  age  of  the  patient ; whether  married  or  single;  length  of 
standing  of  the  disease;  and  if  she  has  borne  children,  the  charac- 
ter of  the  LABOR,  whether  forceps  or  other  artificial  means  were 
used.  The  next  question  amounts  to  this — have  you  any  pain 
or  tenderness  of  any  part?  Where  do  you  ache?  When  is 
the  ACHE  worst.  Does  standing  on  the  feet  make  it  worse?  Under 
what  conditions  is  the  ache  worst?  Sometimes  it  is  well  to  ask 
the  patient  what  the  matter  is.  If  there  is  pain  try  to  get  her 
to  locate  it  for  you;  try  to  get  some  measure  of  its  severity,  when 
it  occurs  and  length  of  time  it  lasts.  Try  to  ascertain  the  onset 
of  the  pain  or  disease,  whether  it  came  on  suddenly  or  gradu- 
ally. Very  frequently  the  patient  will  tell  you  that  it  commenced 
when  she  lifted  a  tub  of  water  or  when  reaching  for  some  article 
on  a  high  shelf.  Ask  the  patient  if  she  sleeps  well ;  insomnia 
being  a  common  complication  of  uterine  disease.  Ask  whether 
or  not  she  suffers  from  headaches  and  in  W'hat  part  of  the  head 
the  pain  is  located;  and  whether  or  not  she  is  more  nervous  than 
she  used  to  be.  Ask  as  to  the  menses;  the  date  of  their  com- 
mencement,   their   regularity    or    irregularity,    the    quantity,    if 


106  DISEASES    OF   WOMEN. 

there  is  pain,  and  when  the  pain  occurs  in  relation  to  the  flow. 
Normal  menstruation  is  preceded  and  accompanied  only 

BY  A  FEELING  OF  WEIGHT  IN  BACK  AND  PELVIS.  "  MeNSTRUAI> 
pain    is    always    a    sign    of    disease."      If    PAIN    PRECEDES     THE 

FLOW  it  is  probably  ovarian  in  origin.  If  the  flow  relieves  the 
pain  an  obstruction  should  be  thought  of;  while  in  cases  in 
which  pain  continues  after  the  flow  starts,  inflammation  of  the 
endometrium  is  probably  the  condition. 

If  amenorrhea  exists,  ascertain  when  the  menses  ceased, 
and  the  supposed  cause.  If  molimina  exist  the  amenorrhea  is 
pathological;  if  not,  physiological.  Pregnancy  should  be  borne 
in  mind  in  all  cases  of  amenorrhea. 

Ask  about  micturition,  whether  it  is  painful  or  too  fre- 
quent; whether  or  not  there  is  a  vaginal  discharge.  If  there  is, 
ascertain  if  possible  its  character,  amount  and  length  of 
standing.  Any  discharge  is  abnormal.  The  thinner  and 
more  glairy,  the  less  important ;  the  thicker  and  more  purulent 
points  to  marked  disease  conditions.  Inquire  about  the  bowels, 
whether  there  is  pain  in  defecation;  if  there  is  constipation  or 
hemorrhoids.  The  occupation  of  the  patient  should  be  ascer- 
tained since  many  forms  of  disease  can  be  rightfully  attributed, 
directly  or  indirectly,  to  it.  If  a  patient  stands  on  the  feet  a 
great  deal,  lifts  heavy  loads  or  does  overhead  work,  displacements, 
congestion,    leucorrhea   and   tubal   diseases   are  suggested. 

The  MARITAL  and  sexual  history  is  of  importance  in  some 
cases.  In  addition  to  inquiring  about  normal  pregnancies, 
character  of  labor,  etc.,  ascertain  if  the  patient  has  ever  aborted, 
the  date,  cause  and  result;  whether  or  not  diseased  conditions, 
such  as  metritis,  followed.  Sometimes  it  is  important  to  know 
whether  intercourse  is  painful  or  distasteful  to  the  patient.  Per- 
haps there  is  lack  of  orgasm,  which  is  quite  common;  or  there 


METHOD    OF    EXAMINATION. 


107 


Fk;.  43. — Liiteral  curv.iture  of  spine.     (From  photo  of  author's  case.) 


108  DISEASES   OF    WOMEN. 

is  a  sexual  perversion.  The  patient  will  usually  drop  a  hint  if 
such  conditions  exist;  if  they  do  you  can  follow  it  up  with  lead- 
ing questions.  Although  the  osteopathic  physician  depends 
very  little  on  the  subjective  method  of  examination,  it  is  prob- 
ably a  good  plan  to  let  the  patients  describe  their  own  cases ; 
which  they  usually  do  with  a  little  assistance. 

EXAMINATION  OF  THE  ABDOMEN.  In  order  to  make 
a  satisfactory  examination  of  the  abdomen  all  clothing  over 
the  part  should  be  removed,  the  woman  then  placed  in  the 
dorsal  position.  By  inspection  the  general  size  and  contour  of 
the  abdomen  and  the  presence  of  dilated  veins  or  lineae  albi- 
cantes  can  be  ascertained.  The  line^e  albicantes  indicate 
that  the  patient's  abdominal  wall  has  been  stretched  beyond  the 
normal  tension  and  are  not  diagnostic  of  a  former  pregnancy, 
since  they  occur  in  tumors,  ascites,  etc.  Fresh  lines  are  glisten- 
ing and  pearly,  old  ones  scarred  and  white. 

The  UMBILICUS  should  be  concave  with  flattening  of  the  ab- 
domen around  it.  If  the  abdominal  cavity  is  distended  from 
gas  or  ascites,  the  umbilicus  becomes  flattened  or  even  slightly 
bulged.  The  enlargement  produced  by  fat  is  different  from  that 
produced  by  ascites  or  fibroid  tumors.  Tumors  or  enlarged 
organs  produce  a  fullness  which  is  most  pronounced  in  the  neigh- 
borhood of  their  origin.  Cause  the  patient  to  breathe  deeply 
and  note  whether  or  not  the  tumor  moves  and  whether  or  not 
the  SKIN  becomes  irregular.  Move  the  patient  into  differ- 
ent positions  in  order  that  it  may  be  ascertained  if  tumor  changes. 
A  change  of  contour  takes  place  in  ascites  and  in  large  cysts. 
Examine  for  scars  resulting  from  operations,  since  laparotomy 
for  various  purposes,  is  such  a  common  operation.  Be  on  the 
lookout  for  evidences  of  such  an  operation  since  the  prognosis 
may  be  materially  changed  by  it. 


METHOD    OF   EXAMINATION.  109 

Palpation  of  the  abdomen  is  the  most  important  form  of 
examination.  At  first  the  physician  should  secure  the  patient's 
confidence  and,  after  the  hands  are  warmed,  proceed  with  both 
hands  to  gently  and  slowly  externally  palpate  the  abdominal 
and  pelvic  organs.  The  patient  being  in  the  dorsal  position,  the 
LIMBS  SHOULD  BE  flexed  on  the  abdomen  in  order  to  relax  the 
abdominal  muscles.  At  first  the  pressure  should  be  light,  then 
gradually  increased  until  the  deeper  structures  are  reached. 
Note  tone,  fluctuation,  irregularities,  displacement  of  parts,  and 
tenderness,  all  of  which  are  necessary  to  differentiate  between 
tumors,  fecal  impaction,  exudates,  enlargement  or  distention  of 
organs,  displacement  of  viscera,  etc.  A  contractured  condition 
OF  the  abdominal  w^\lls  is  suggestive  of  some  irritative 
disease  of  the  viscera,  covered  by  it.  Hilton  explained 
such  conditions  by  the  assumption  that  the  nerve  supply  of 
A  viscus  and  its  coverings  comes  from  the  same  source.  A 
hard,  un^delding  abdominal  wall  is  symptomatic  of  peritonitis, 
acute,  if  fever  and  tenderness  exist;  chronic  peritonitis  with  ad- 
hesions, if  there  is  neither  fever  nor  tenderness.  A  tightening 
of  the  tissues  beneath  the  wall  should  be  noted  and  carefully 
palpated,  since  such  are  indicative  of  adhesions.  Peritoneal  ad- 
hesions, whether  from  an  operation  or  inflammation  from  other 
causes,  can  often  be  diagnosed  in  this  way. 

If  tenderness  is  found,  as  certain  what  organ  is  affected,  whether 
the  uterus  or  its  appendages.  Tenderness  immediately  above  the 
pubic  bones  indicates  cystitis,  congestion  or  inflammation  of 
the  uterus;  tenderness  on  either  side  of  the  median  line  below 
the  umbilicus,  disease  of  the  Fallopian  tubes  or  ovaries.  Sore- 
ness on  either  side  of  the  umbilicus  indicates,  if  deeply  seated, 
an  enlargement  of  the  lymphatic  glands  which  drain  the  uterus. 
This  is  indicative  of  uterine  inflammation.     In  such  cases  a  soft 


Fio.  44. — Twisted  pelvis,  slightly  exaggerated.     (From  photo  of  autlior's  case.) 


METHOD    OF    EXAMINATION.  Ill 

tumor  varying  in  size  from  that  of  a  marble  to  a  walnut  is  found 
at  this  point. 

In  diseased  conditions  of  the  uterus,  pulsation  or  throbbing 
of  the  arteries  in  the  neighborhood  of  the  uterus  is  frequently 
found.  In  case  of  ovarian  trouble  this  pulse  is  found  along  the 
course  of  the  iliac  arteries.  If  this  throbbing  is  found  in  the 
neighborhood  of  the  umbilicus  or  immediately  above,  it  indi- 
cates some  intestinal  trouble.  If  found  at  the  pit  of  the  stomach 
it  is  a  symptom  of  gastric  trouble,  usually  catarrh.  This  throb- 
bing becomes  very  painful  at  times,  even  preventing  sleep  by 
its  constant,  annoying,  hard  pulsation.  I  have  seen  cases  in 
which  the  bed  was  shaken  by  this  throbbing  at  each  heart  beat. 
It  is  supposed  to  be  caused  by  a  local  constriction  of  the  artery 
due  to  vaso-motor  irritation. 

Care  should  be  taken  in  palpating  just  below  the  umbilicus 

not  to  MISTAKE  THE  BODY  OF  THE  FIFTH  LUMBAR  FOR  AN  ANEU- 
RISM. Patients  ^^i  1  come  with  a  supposed  aneurism  of  the  iliac 
artery,  there  being  found  a  localized  tumor  with  pulsation.  This 
is  particularly  true  of  thin  patients.  The  tumor  is  the  body  of 
the  fifth  lumbar;  the  pulsation  the  result  of  pressure  on  the  iliac 
arter}'.  Sometimes  tumors  are  found,  either  uterine  or  ovarian, 
which  are  mistaken  for  impaction  or  vice  versa;  the  character 
of  the  enlargement  indicating  which  it  is.  If  the  tumor  is  irreg- 
LAR  and  nearly  round  or  globular  it  points  to  a  fibroid  tumor; 
if  oblong  and  there  is  a  history  of  constipation  and  reflex  gastric 
disturbances,  it  points  to  an  impaction  of  the  colon. 

Another  test  for  determining  whether  the  tumor  is  of  abdom- 
inal or  pelvic  origin  is  made  by  attempting  to  pass  the  hand 
DOWNWARD  JUST  ABOVE  the  SYMPHYSIS  pubis.  If  the  tumor 
is  PELVIC  and  rising  into  the  abdominal  ca\ity,  the  hand  can 
NOT  BE  PKESSED  BELOW  the  tumor;  but  if  abdominal,  it    can  be 


112  DISEASES   OF   WOMEN. 

SUNKEN  INTO  THE  PELVIC  CAVITY  below  the  tumor.  Some  men- 
tion the  presence  of  intermittent  contractions  in  fibroid  tumors; 
these  contractions  can  be  felt  in  some  soft  fibroids,  not  in  all. 

The  temperature  of  the  abdominal  wall  should  be  noted.  A 
cold  or  clammy  condition  of  the  abdominal  wall  is  indicative  of  a 
lowered  vitality  of  the  parts  covered  by  it.  Some  form  of  uter- 
ine disease  is  usually  present  in  such  cases.  If  it  occurs  in  the 
region  of,  or  follows  the  course  of  a  nerve  trunk,  it  can  safely 
be  attributed  to  a  lesion  of  the  rib  or  vertebra  in  relation.  The 
"Old  Doctor"  says  in  reference  to  a  general  coldness  of  the  abdo- 
men that  "the  OMENTUM  IS  DISPLACED."  When  we  consider 
the  position  and  form  of  this  peculiar  apron-shaped  structure, 
such  a  thing  seems  very  reasonable.  In  dissections  made  by 
the  author  the  omentum  was  found  to  be  displaced  or  diseased 
in  many  subjects,  and  in  all  in  which  uterine  disease  had  existed. 
A  hot,  dry  abdominal  wall  suggests  peritonitis  especially  so  if 
the  integument  is  reddened.  Dryness  of  the  skin  often  accom- 
panies kidney  disease  and  is  suggestive  of  uremic  disturbances. 
In  such  cases  there  is  a  pasty  complexion,  loss  of  strength  and 
dysmenorrhea. 

By  PERCUSSION  is  ascertained  the  solidity  of  the  enlarge- 
ment. In  ascites  the  percussion  note  is  changed  with  different 
positions  of  the  patient.  If  the  patient  is  placed  on  the  back, 
dullness  is  elicited  by  percussion  on  the  sides,  while  in  the  median 
line  the  percussion  note  is  fiat  or  tympanitic.  If  the  abdomen 
is  swollen  and  tympanitic,  it  is  due  to  gas  in  the  bowels;  or  if  it 
is  also  tender,  to  peritonitis,  which  most  often  follows  a  sudden 
cessation  of  the  menses. 

Sometimes  auscultation  is  used  in  cases  of  suspected  aneu- 
rism and  in  some  other  abdominal  enlargements.  In  an  aneu- 
rism a  BRUIT  is  heard  almost  svnchronous  with  the  heart  beat. 


METHOD    OF    EXAMINATION.  113 

Vascular  murmurs  or  soufles  may  also  be  heard  over  large 
uterine  tumors  and  the  gravid  uterus.  Fetal  heart  sounds  are 
detected  as  early  as  the  fourth  month  of  pregnancy  and  are  com- 
pared to  the  ticking  of  a  watch  beneath  a  pillow.  Friction 
sounds  are  sometimes  detected  in  chronic  peritonitis. 

EXAMINATION  OF  THE  VULVA.  It  is  seldom  necessary 
to  use  inspection  of  the  vulva  in  the  examination  of  g3aiecologi- 
cal  cases.  A  routine  practice  of  such  an  examination  is  to  be 
condemned  unless  there  are  indications,  and  good  ones  at  that, 
of  vulvar  disease.  On  the  other  hand,  this  form  of  examination 
affords  information  as  to  the  cleanliness  of  the  patient,  elonga- 
tion or  HYPERTROPHY  of  the  LABIA,  size  of  the  clitoris  or  adhered 
prepuce,  vaginal  discharges,  and  the  anomalies  of  the  hymen 
or  its  remains,  which  things  are  important  in  many  cases.  As  a 
rule  INSPECTION  of  the  external  genitals  should  be  made  when 
there  is  pain,  soreness,  pruritus  or  swelling;  in  the  young 
when  masturbation  is  suspected,  since  it  affords  the  best  evi- 
dence. When  the  patient  speaks  of  something  having  "dropped 
DOWN, ' '  which  term  is  used  by  the  laity  to  describe  procidentia, 
inspection  is  indicated.  The  patient  should  be  placed  in  the 
dorsal  position  with  the  limbs  flexed  and  separated.  It  is  best 
to  use  an  endoscope  with  a  small  electric  light,  or  better  still 
reflected  sunlight  by  means  of  a  mirror  held  directly  in  the  sun- 
shine. By  these  means  the  parts  can  be  thoroughly  inspected 
with  little  exposure  of,  or  embarrassment  to  the  patient.  Hem- 
orrhoids, if  present,  will  be  the  first  abnormal  condition  noticed. 
The  external  forms,  which  are  usually  fibrous  in  character,  can 
be  seen  as  a  bunch  or  protrusion  around  the  anus.  The  size 
and  condition  of  the  labia  are  next  noted;  the  nymphae  being 
large,  red  and  irritable  in  cases  of  masturbation.  Separation 
of  the  greater  lips  then  reveals  the  condition  of  the  vulva,  whether 

8 


1J4  DISEASES   OF    WOMEN. 

or  not  there  Ls  inflammation,  growths,  a  swollen  condition  or 
prolapsus  of  the  walls.  By  causing  the  patient  to  strain,  as  at 
stool,  the  DEGREE  OF  PROLAPSUS  of  the  Vaginal  walls  is  the  better 
ascertained.  There  may  be  tears  of  the  perineum  and  labia 
produced  by  parturition.  There  may  be  irritable  spots  caus- 
ing VAGINISMUS.  These  localized  spots  of  irritation  often 
result  from  an  imperfectly  healed  hymen  which  has  been 
ruptured.  Awkward  coitus,  the  use  of  instruments,  astring- 
ents or  very  hot  douches  frequently  injure  the  vulva,  thus  setting 
up  an  irritation.  If  the  patient  is  a  young  girl  and  masturba- 
tion is  suspected,  the  diagnosis  can  usually  be  made  by  examina- 
tion of  the  clitoris  and  lesser  lips,  they  being  found  irritable  and 
inflamed.  The  meatus  urinarius  should  be  examined  for  dis- 
eased conditions  since  it  often  presents  a  red,  angry  appearance 
in  many  types  of  uterine  disease.  In  chronic  gonorrhea,  it 
is  RED  and  irritable  and  remains  thus  for  many  years  after  a 
severe  attack  of  gonorrheal  urethritis.  Occasionally  a  caruncle 
is  discovered  attached  to  the  meatus  and  is  the  cause  of  much 
local  discomfort  and  inconvenience. 

EXAMINATION  OF  THE  VAGINA.  Vaginal  examina- 
tion should  not  be  made  in  girls  near  the  age  of  puberty 
unless,  by  other  methods,  you  have  failed  to  diagnose  and  cor- 
rect the  cause  of  the  disease.  In  the  case  of  unmarried  women 
it  should  not  be  attempted,  unless  the  indications  for  such  an 
examination  are  very  strong.  These  indications  are  persist- 
ent BACKACHE  at  or  below  the  small  of  the  back,  headache, 
neckache,  menstrual  pain,  bladder  disturbances,  hem- 
orrhoids, aching  of  limbs  and  constipation.  If  the  above  dis- 
orders do  not  yield  to  external  treatments,  at  least  a  vaginal 
examination,  should  be  given.  If  you  have  a  patient  belong- 
ing to  either  class  remember  that  the  rectal  examination  is  usual- 


METHOD    OV    EXAMINATION.  115 

ly  sufficient,  and  avoid  if  possible  the  vaginal  examination. 
Reed  says:  "Youth  and  virginity  should  always  be  looked 
upon  as  contraindications  for  such  an  exploration  unless  in  the 
presence  of  counter-balancing  reasons:  such,  for  instance,  as  the 
presence  of  all  the  menstrual  phenomena,  the  flow  excepted, 
suggesting  the  possible  retention  of  the  menstrual  fluid;  or  in 
the  presence  of  an  offensive  discharge  associated  with  remote 
pelvic  symptoms;  or  to  investigate  the  origin  of  persistent  hem- 
orrhage."  It  is  even  useless  in  many  of  the  above  cases.  The 
average  physician  is  too  prone  to  make  such  examinations  on 
the  slightest  provocation,  which  often  do  more  harm  than  good. 

On  the  contrary,  in  the  case  of  a  married  woman  whose 
symptoms  point  to  a  pelvic  disease,  always  make  the  examina- 
tion. If  the  patient  has  passed  the  menopause,  all  symptoms 
of  a  pelvic  character  should  be  regarded  with  suspicion,  and 
measures  adopted  for  a  thorough  examination,  especially  if 
hemorrhage  has  occurred.  Examinations  should  not  be  made 
when  the  patient  is  menstruating  unless  there  is  an  acute  dis- 
placement causing  painful  reflex  troubles ;  it  being  disagreeable  and 
sometimes  injurious.  Always  secure  the  consent  of  the  patient 
to  be  examined,  or  that  of  an  immediate  relative  or  guardian; 
never  making  a  vaginal  examination  without  it. 

POSITIONS.  The  principal  positions  used  for  examining 
a  gynecological  patient,  are  the  Sims  and  dorsal.  The  other 
positions  used  are  the  erect,  genu-pectoral  and  Trendelen- 
BERG,  that  is,  with  the  hips  elevated. 

In  making  the  examination  of  a  patient  in  the  dorsal  posi- 
tion, the  patient  should  lie  with  her  heels  about  six  inches  apart 
and  the  knees  widely  .separated.  All  bands  and  constrictions 
around  the  abdomen  should  be  removed.  The  bladder  and 
bowel  should  be  evacuated  before  a  vaginal  or  rectal    examina- 


116 


DISEASES   OF   A^OMEN. 


tion  is  attempted.  Usually  it  is  not  necessary  to  expose  any 
part  in  making  the  digital  examination.  The  dorsal  position  is 
used  in  making  the  bimanual  examination,  and  in  mak  ing  an 


Fig.  45. — L.vmphatic  >;liindH  of  lumbar  region  that  drain  the  uterus. 

examination  with  the  bivalve  speculum.  For  the  digital  exami- 
nation the  Sims  position  is  to  be  preferred  for  reasons  named 
below. 


METHOD    OF    EXAMINATION. 


117 


In  the  Sims  position    the    patient  lies  on  her  left  side,  half 
turned  over  on  the  front;  both  limbs  are  flexed,  the  right  slightly 


|f 


^M 


A 


1 


Fig.  4(i. — Sims  position. 


more  than  the  left;  the  left  side  of  the  face  rests  on  the  pillow, 
the  left  breast  touches  the  table  and  the  left  arm  is  placed  behind 
the  body.  I  prefer  this  position  in  examination,  first,  because 
a  higher  exploration  of  the  pelvic  cavity  can  be  made;  second, 
by  turning  the  patient  into  the  dorsal  position  you  can  make 
the  bimanual  examination;  third,  you  have  the  advantage  of 
both  positions  without  withdrawing  the  finger;  and  fourth,  the 
patient's  face  is  turned  from  you  thus  relieving  her  of  embarass- 
ment.  Backward  displacements  of  the  uterus  can  be  corrected 
at  the  time  of  examination  with  the  patient  in  this  position;  which 
is  not  easily  done  with  the  patient  in  the  dorsal  position.  The 
Sims  speculum,  which  is  probably  the  best  one  for  ordinary  use, 
is  used  only  in  this  position. 


118 


DISEASES    OF    WOMEN. 


The  genu-pectoral  position  is  used  principally  in   treating; 
that  is,  in  replacing  a  retro-deviation  or  introducing  a  tampon, 


Fig.  47. — The  genu-pectoral  position, 


rather  than  for  diagnostic  purposes.  The  patient  rests  on  her 
knees,  upper  part  of  the  chest,  left  side  of  the  face  and  right 
fore-arm.  The  thighs  should  be  perpendicular,  the  uterus  then .. 
if  in  position,  has  a  tendency  to  assume  the  vertical  position 
with  the  heavy  end  or  fundus  down.  The  tendency  of  the  uterus 
to  assume  the  perpendicular  when  the  patient  is  in  the  genu- 
pectoral  position  is  an  important  point  in  the  treatment  of  all 
displacements.  A  great  many  displacements  can  be  cured' by 
the  patient  placing  herself  in  this  position  once  or  more  times 
a  day  for  some  time. 


METHOB    OF    EXAMINATION. 


119 


The  erect  position  is  used  in  the  examination  of  cases  of  sus- 
pected prolapsus;  the  degree  of  prolapsus  being  better  ascer- 
tained if  it  is  made  in  this  position.  The  patient  should  be  on 
the  physician's  left  with  the  left  foot  resting  on  the  round  of 
the  stool.  The  physician  should  sit  on  the  stool  at  the  pa- 
tient's left  and  introduce  the  index  finger  of  the  right  hand  into 
the  vagina. 

The  Trendelenberg  position  is  seldom  used  for  diagnostic 
purposes,  but  is  used  in  operations  on  the  abdomen,  in  treating 


Fic.  48  — Trendelenberg  i)ositi()n. 


a  prolapsed  condition  of  the  bowels  or  anteflexion  of  the  uterus. 
In  this  position  the  intestines  are  drawn  off  the  pelvic  organs, 
and  is  a  position  to  be  recommended  in  the  treatment  of  all  ante- 
deviations  of  the  uterus. 


120  DISEASES    OF    WOMEN. 

VAGINAL  EXAMINATION.  In  making  the  vaginal  ex- 
amination I  make  it  a  practice  to  place  the  woman  on  her  left 
side  or  in  the  Sims  position  for  the  above  mentioned  reasons, 
then  turn  her  over  on  her  back  for  the  performance  of  the  biman- 
ual if  it  can  not  satisfactorily  be  made  with  her  on  the  side.  The 
index  finger  of  the  right  hand  should  be  carefully  lubri- 
cated with  glycerine,  vaseline  or  some  other  suitable  lubricant. 
With  the  left  hand  the  clothes  can  be  cleared  away  from  the 
hips  so  as  to  make  a  passage  for  the  examining  finger,  which  is 
passed  onward  until  it  reaches  the  cleft  between  the  buttocks; 
the  finger  is  next  passed  forward  over  the  anus,  perineal  body 
and  fourchet  until  the  pulp  of  the  finger  reaches  the  vaginal 
orifice.  By  doing  this  the  clitoris  is  avoided,  thereby  prevent- 
ing sexual  irritation  and  contraction  of  the  muscles  of  the  peri- 
neum. The  physician  must  be  careful  not  to  pass  the  finger  into 
the  rectum  by  mistake.  This  can  be  avoided  if  their  axes  are 
remembered,  the  axis  of  the  vagina  being  upward  and  back- 
ward; that  of  the  rectum,  upward  and  forward.  No  force  is 
required  to  pass  the  finger  into  the  vagina  of  a  woman  whose 
hymen  has  been  ruptured,  whereas  some  force  is  necessary  to 
overcome  the  resistance  of  the  sphincter  ani.  The  finger,  now 
being  at  the  vaginal  orifice,  should  be  carried  backward  and  up- 
ward along  the  walls  of  the  vagina  until  its  upper  limits  are  felt. 
While  doing  this  the  physician  should  note:  first,  the  condi- 
tion of  the  pelvic  floor  and  vaginal  orifice,  if  there  is  loss  of 
tonicity,  which  makes  the  vagina  patulous,  the  absence  or  pres- 
ence of  tender  spots  which  produce  a  spasm  or  contraction; 
SECOND,  the  WALLS,  Condition  of  the  rugae,  whether  there  is 
absence  or  presence  of  the  same;  examine  for  secretions,  heat, 
tumors  attached  to  the  walls,  for  foreign  bodies  such  as  pessaries 
that  have  been  placed  there  for  the  purpose  of  treatment;   also 


METHOD    OF    EXAMINATION. 


121 


note  the  length  and  condition  of  the  walls  and  the  condition  of 

the  anterior  and  posterior  fornices. 

Third,  note  the  cervix,  its 
size,  shape  and  consistency 
of  the  lips,  they  being  of  ubout 

the  CONSISTENCY  OF  THE  END 
OF    THE      NOSE       if     HEALTHY, 

and  about  the  consistency 
OF  THE  LIPS  if  diseased  or 
if  PREGNANCY  exists.  The 
shape  of  the  cervix  is  conical 
with  a  smooth  surface.  Its 
size  varies,  it  usually  pro- 
jecting into  the  vagina  about 
one  inch  and  is  about  three- 
quarters  of  an  inch  in  diam- 
eter. As  a  rule  it  looks 
larger  than  it  feels.  Examine 
carefully  to  ascertain  if  it  is 
drawn  to  one  side,  if  fixed  or 
mobile,  or  if  split  with  cica- 
trices radiating  from  it  to 
the  vaginal  roof.  Often  in 
such  cases  of  marked  lacera- 
tion, one  lip  is  bent  consider- 
ably, resembling  in  shape  a 
sled  runner.  If  both  Hps 
diverge,  the  name  "bell 
shape"  has  been  applied. 
The  lip  on  the    concave  side 

Fig.  49. — Different  forms  of  abnormal  .        ,  ,      ,     •  i      j     a„,. 

cervices.  IS  elongated  in   marked   tlex- 


122  DISEASES   OP   WOMEN. 

ions.  Often  in  an  infantile  uterus  there  is  a  cervical  flexion.  If 
the  CERVIX  is  markedly  conical  or  pointed,  it  points  to  under- 
development, perhaps  an  infantile  uterus.  If  cylindrical  and 
the  end  appears  to  be  obliquely  truncated,  an  error  in  develop- 
ment is  also  indicated,  and  sterility  is  the  common  sequel. 

Note  the  direction  of  the  cervix  and  its  relation  to  the 
vaginal  walls,  because  the  diagnosis  between  a  version  and  a 
flexion  depends  upon  the  position  of  the  cervix.  The  tip  of  the 
coccyx  can  be  felt  on  a  level  with  the  end  of  the  cervix.  This 
can  best  be  ascertained  with  the  patient  in  the  dorsal  position. 

Fourth,  note  theos,  its  size  and  shape;  it  being  a  dimple 
in  the  nullipara,  a  transverse  slit  in  the  mulitparous  woman. 
(See  Figs.  17  and  18.)  The  cervix  may  be  slit  onone  or  both  sides, 
thus  destroying  the  os  externum  and  more  or  less  exposing  the 
cervical  canal.  This  permits  of  a  protrusion  of  the  endometrium, 
such  condition  receiving  the  name  of  ectropion.  Bodies  pro- 
jecting through  the  os  should  be  noted,  such  as  polypi,  can- 
cerous masses,  stem  pessaries  or  fragments  of  abortion.  In  the 
Infantile  uteres  the  os  is  very  small;  in  most  cases  of  subinvolution, 
it  is  patulous.  The  next  thing  to  be  noted  is  the  corpus  uteri 
or  body.  By  bringing  pressure  against  the  anterior  fornix  with 
the  examining  finger,  the  uterus  can  be  felt  if  it  is  in  normal  posi- 
tion or  ante-deviated.  It  moves  readily  with  slight  pressure; 
the  cervix  also  changing  its  position. 

The  OVARIES  AND  Fallopian  tubes  if  normal,  can  be  felt 
with  difficulty  in  a  favorable  subject.  If  the  patient  is  large 
or  the  abdominal  wall  tender,  they  can  not  be  outlined ;  but  in 
ordinary  cases  they  can  be  distinguished  if  congested,  inflamed 
or  displaced.  Pressure  on  a  diseased  ovary,  causes  a  pain  to  be 
referred  to  the  iliac  fossa  of  the  corresponding  side. 

Fifth,  the  posterior  fornix  is  concave  when  felt  from  below 


METHOD    OF    EXAMINATION. 


123 


upward;  normally,  it  has  the  feeling  of  the  inside  of  the  angle  of 
the  mouth.  Note  whether  this  cavity  is  lessened  by  the  presence 
of  adhesions  or  some  foreign  body.  See  if  any  lump  can  be  felt 
projecting  from  the  pouch  of  Douglas.  A  body  felt  through  the 
posterior  fornix  is  usually  a  retro-deviated  uterus,  but  may  be  a 
prolapsed  ovary,  feces  or  a  fibroid  tumor  attached  to  the  pos- 
terior wall  of  the  uterus. 

Sixth,  examine  the  anterior  fornix  ;  note  its  shape,  depth, 
and  if  any  body  can  be  felt  through  it.  If  so,  it  is  usually  the 
anteflexed  uterus  or  a  fibroid  tumor.  This  fornix  may  be  im- 
pinged upon  by  retroversion  of  the  uterus,  or  the  cervix  and  the 


Fig.  50. — The   bimanual  examiuiitiou  in   the  dorsal 
posture.    (Byford  from  Slirocder.) 

vaginal  wall  may  have  grown  together  as  a  result  of  a  vaginitis; 
this   sometimes   obliterating   both   the   anterior   and  posterior 
fomices. 

From  this  examination  we  have  learned  of  the  tone  and 
POSITION  of  the  cervix,  consistency  of  the  vaginal  walls  and  size 
of  the  external  os,  these  being  only  preliminary  to  the  bimanual 
examination. 

BIMANUAL    EXAMINATION.     The    bimanual     method     is 


124 


DISEASES   OF   WOMEN. 


one  of  very  great  importance  in  the  examination  of  the  pelvic 
contents,  and  is  used  very  extensively  by  the  osteopath.  It 
consists  of  palpation  of  the  uterus  between  the  hands,  one  internal 
and  the  other  external.  This  is  done  in  two  ways,  per  vagina 
and  per  rectum.     It  is  performed  with  the  patient  iti  the  dorsal 


Fig.  51. — Bimanual  exaininatioii  of  the  uterus  per  rectum. 

or  Sims  position,  preferably  the  former,  with  the  limbs  flexed. 
After  making  a  digital  examination  in  the  Sims  position,  if 
the  bimanual  can  not  be  satisfactorily  made  while  in  that  posi- 
tion, turn  the  patient  into  the  dorsal  position  without  removing 


METHOD    OF    EXAMINATION.  125 

the  internal  finger.  With  right  index  finger  (sometimes  second 
finger  also)  in  vagina  against  the  cervix,  and  the  left  with  the 
ulnar  side  superior  to  the  uterus,  which  prevents  retro-displace- 
ment, by  approximating  the  two  hands,  the  uterus  can  be  felt 
as  a  lump  or  body  between  them  if  it  is  in  normal  position,  ante- 
flexed  or  anteverted;  but  if  it  is  retro-displaced  the  tips  of  the 
fingers  can  be  distinctly  palpated,  the  tissues  alone  separating 
them.  Sometimes  in  cases  of  anteversion  it  is  hard  to  reach  the 
cervix,  and  in  order  to  lengthen  the  examining  finger  the  remain- 
ing fingers  of  the  hand  should  be  tightly  flexed,  and  considerable 
pressure  brought  to  bear  on  the  perineal  body.  This  causes  no 
pain  and  by  so  doing  the  physician  can  reach  at  least  one 
inch  further  along  the  cleft  between  the  nates.  The  external  hand 
should  be  steadily,  not  spasmodically,  depressed,  the  pressure 
being  gradually  increased  until  the  deep  structures  can  be  out- 
lined. 

The  OBJECT  of  the  bimanual  examination  is  to  determine 
the  POSITION,  size  and  shape  of  the  uterus,  and  to  recognize 
any  enlargement  or  growth  that  may  be  in  the  pelvis;  also  to 
confirm  the  diagnosis  made  by  external  and  vaginal  examina- 
tion. The  CONDITION  OF  THE  ADNEXA  is  also  ascertained  by  this 
method.  By  pressure  with  the  external  hand,  the  uterus  being 
steadied  by  the  internal  finger,  the  broad  ligaments,  tubes  and 
ovaries,  if  at  all  diseased,  can  be  outlined.  In  normal  cases  they 
can  with  difficulty  be  outlined.  In  order  to  differentiate  between 
the  normal  and  abnormal,  it  is  necessary  to  know  what  is  found 
in  a  normal  case  by  vaginal  and  bimanual  examinations.  The 
following  is  a  description  of  the  conditions  found  in  a  nulliparous 
married  woman  on  vaginal  and  bimanual  examination:  "The 
ostium  vaginae  is  patulous  and  admits  two  fingers;  vaginal 
walls  moist,  and  rugous,  with  no  abnormalities;  vaginal  portion 


126  DISEASES    OF    WOMEN. 

of  cervix  normal  in  size;  os  uteri  felt  like  a  dimple  looking  down- 
ward and  backward.  No  bodies  are  felt  through  the  lateral 
and  posterior  fornices,  which  are  concave  on  the  vaginal  aspect 
and  have  the  feeling  on  pressure  of  the  angle  of  one's  mouth. 
In  the  anterior  fornix  a  body  is  felt,  which  on  bimanual  examina- 
tion is  discovered  to  be  the  uterus  lying  to  the  front  and  not 
enlarged.  The  vagina  and  cervix  meet  at  about  a  right  angle. 
Bimanual  exploration  of  the  posterior  fornix  reveals  nothing  dis- 
tinctly palpable.  The  patient  complains  of  no  pain  during 
THE  WHOLE  EXAMINATION  and  has  no  symptoms  referable  to  the 
pelvis. ' ' 

In  case  there  is  inflammation  of  the  vagina  or  of  the  uterus, 
bimanual  examination  is  difficult  and  the  rectal  examination 
should  be  substituted.  The  examination  is  also  difficult  in  stout 
nuUiparous  women  in  whom  the  abdominal  walls  are  very  thick. 
At  FIRST,  the  bimanual  method  is  unsatisfactory,  but  by 
perseverance  it  becomes  more  satisfactory  in  recognizing  uterine 
displacements  and  pelvic  growths.  It  is  a  very  important  ex- 
amination and  by  practice  wonderful  accuracy  of  touch  can  be 
acquired. 

The  OBJECT  of  these  various  methods  of  examination  is  to 
ascertain  (1)  the  amount  of  tenderness  and  inflammation;  (2) 
degree  of  mobility,  which  mobility  is  determined  by  the  presence 
and  extent  of  exudates  and  adhesions;  and  (3)  the  position  of 
the  uterus,  which  is  the  least  important  as  compared  with  the 
other  two. 

A  TENDER,  inflamed  uterus  is  always  pathological  and  needs 
treatment.  An  immobile  uterus  is  usually  pathological.  If 
tenderness  complicates  the  loss  of  mobility  it  is  pathological 
in  EVERY  case.  If,  on  palpation,  no  tenderness  is  found  in  the 
uterus,  I  doubt  the  advisability  of  giving  local  treatments  even 


METHOD    OF    EXAMINATION.  127 

though  adhesions  are  present,  unless  there  are  pressure  symp- 
toms.     A    DISPLACED    UTERUS    IS  NOT    ALWAYS  PATHOLOGICAL    and 

replacement  should  not  be  attempted  unless  congestion  or  in- 
flammation is  present,  in  which  case  there  will  be  tenderness  on 
palpation.  In  some  cases  pressure  symptoms  accompany  the 
displacement,  in  which  cases  the  uterus  should  be  replaced. 

EXAMINATION  WITH  THE  SPECULUM.  The  speculum 
is  an  instrument  so  arranged  that  the  two  vaginal  walls  can  be 
separated,  bringing  the  os,  cervix,  and  parts  of  the  vaginal  walls 
into  view.  There  are  various  kinds  of  specula  which  pattern 
after  two  forms,  the  univalve  or  Sims  and  the  bivalve 

The  Sims  speculum  consists  of  two  blades  of  unequal  size 
running  at  right  angles  to  a  shank  which  unites  them.  The 
smaller  blade  is  used  for  the  examination  of  nullipara,  the  larger 


Fig.  52. — Sims  speculum. 

for  examining  women  with  large  vaginae,  and  for  operating.  It 
acts  as  a  retractor,  pulling  the  posterior  wall  from  the  anterior, 
thereby  admitting  air  into  the  vagina,  and  exposing  the  upper 
part  of  the  canal  with  the  cervix  and  vaginal  wall. 

To  introduce  the  speculum,  the  patient  should  be  in  the 
Sims  position,  which  has  been  previously  described.  If  the 
iNTROiTus  vaginae  is  Small, the  upper  or  right  buttock  and  labium 
should  be  lifted  by  the  left  hand,  then  the  instrument,  which  has 


128 


DISEASES    OF    WOMEN. 


been  previously  warmed  and  oiled,  should  be  taken  hold  of  with 
the  right  hand,  and  the  blade,  held  in  line  with  the  vaginal  axis, 
gradually  pressed  into  the  vagina,  keeping  it  well  back  against 
THE  POSTERIOR  WALL.  To  successfully  do  this  remember  the 
AXIS  of  the  vagina;  it  being  toward  the  hollow  of  the  sacrum,  not 
in  the  long  axis  of  the  body. 

The  ADVANTAGES  of  this  speculum  are,  its  easy  introduction, 
its  simplicity,  the  freedom  from  pain  in  its  use,  the  view  it  gives 
of  the  different  parts  in  their  normal  position,  especially  the 
anterior  vaginal  wall,  and  the  advantage  it  gives  for  manipula- 
tion of  the  uterus  with  other  instruments  if  such  are  used.  The 
disadvantage  is  that  it  is  necessary  to  have  an  assistant  to  hold 
it  in  order  to  make  a  satisfactory  examination. 

The  BIVALVE  SPECULUM  cousists  of  two  blades  so  hinged 

together  that  they  may  be  sepa- 
rated by  pressure  on  a  lever. 
To  introduce  the  bivalve  spec- 
ulum, the  woman  should  be  in 
the  dorsal  position  with  the 
vulva  exposed ;  the  two  lips  are 
separated  with  the  left  hand, 
the  point  of  the  instrument, 
after  it  has  been  warmed  and 
lubricated,  is  introduced  in 
nullipara,  so  as  to  conform  with 
the  external  opening,  but  as 
soon  as  the  point  enters  it  should  be  turned  so  that  the  blades 
become  antero-posterior.  In  multipara  it  is  not  necessary  to 
start  the  speculum  in  edgewise  but  introduce  directly  without 
turning.  The  instrument  should  then  be  lightly  pressed  inward, 
downward  and  backward  until  it  reaches  the  cervix.     The  blades 


Fi(i.  53. — Bivalve  speculum. 


METHOD    OF    EXAMINATION.  129 

are  then  opened  and,  as  soon  as  the  cervix  is  brought  to  view, 
are  fixed  with  a  screw.  The  os  and  cervix  can  be  seen  by  the 
use  of  this  instrument,  but  they  are  forced  into  a  distorted 
position,  thus  the  uterus  is  so  changed  that  its  position  can  not 
be  accurately  diagnosed  by  the  use  of  this  kind  of  a  speculum. 
There  are  various  forms  of  these  specula  which  differ  in  size, 
manner  of  separating  the  blades  and  the  material  out  of  which 
they  are  made. 

Next  comes  the  question — when  should  a  speculum  be  used? 
In  my  practice  I  have  very  little  use  for  a  speculum  and  seldom 
use  it,  and  the  longer  I  am  in  practice,  the  less  use  I  have  for  instru- 
ments in  general  and  specula  in  particular.  If  I  have  a  case  of 
erosion  of  the  cervix,  of  some  fungus  formation  that  I  cannot 
differentiate  by  digital  examination  from  a  laceration  or  cancerous 
growth,  an  examination  with  a  speculum  is  indicated.  Some- 
times it  is  used  in  the  introduction  of  a  sound,  but  I  think  in  most 
cases  that  is  unnecessary.  It  is  used  by  some  physicians  in  order 
to  tampon  the  vagina  or  introduce  a  pessary,  but  these  should 
not  be  used  by  the  osteopathic  physician  except  in  rare  cases, 
hence  the  speculum  is  not  a  necessary  instrument  even  in  these 
cases. 

The  ENDOSCOPE  is  used  to  illuminate  the  cavity  of  the  vagina 
when  a  speculum  is  used,  and  is  very  useful  since  the  patient  can 
be  examined  in  a  dark  room  or  at  least  not  in  front  of  a  window. 
It  consists  of  an  electric  battery  connected  with  a  one  or  more 
candle  power  lamp  with  a  contrivance  for  attachment  to  the 
speculum.  The  use  of  a  mirror,  by  which  the  sun  light  can  be 
reflected  and  focussed  directly  on  the  parts  exposed,  makes  the 
best  possible  light  that  can  be  obtained.  The  disadvantages 
are  that  an  assistant  and  the  direct  rays  of  the  sun  are  needed. 

I  want  to  condemn  the   use  of  the  speculum  as  is  ordinarily 


130  DISEASES    OF    WOMEN. 

practiced  by  the  physician.  The  exposure  and  nervous  shock, 
in  making  the  examination  do  more  harm  than  good,  in  most 
cases.  Again,  the  practice  of  using  it  from  one  to  six  times 
each  week,  weakens  the  vaginal  walls,  admits  air  into  the  uterus, 
and  has  a  tendency  to  produce  displacements  by  stretching  the 
vaginal  walls  and  changing  the  intra-pelvic  air  pressure. 

THE  SOUND.  The  uterine  sound  consists  of  smooth  nickel 
or  silver  plated  copper  wire,  blunt  at  the  point  and  with  cor- 
rugated flat  handle,  as  shown  in  Fig.  54. 


Fi(i  .54 — Flexible  KOiiiKi. 

It  can  be  bent  into  various  shapes  so  that  it  will  accomo- 
date itself  to  the  various  displacements  of  the  uterus.  It  is  used 
more  for  therapeutical  than  for  diagnostic  purposes.  In  diag- 
nosis it  is  used  to  ascertain  the  length  of  the  uterine  cavity,  the 
size  of  the  canal,  mobility  of  the  uterus  and  its  position  in  the 
pelvis.  For  therapeutical  purposes  it  is  used  to  correct  displace- 
ments, especially  flexions.  I  think  its  use  is  abused  in  a  great 
many  cases.  The  uterus  is  lined  with  a  delicate  mucous  mem- 
brane or  endometrium  and  can  be  readily  injured,  or  the  wall 
punctured  by  the  introduction  of  any  foreign  body  such  as  a 
probe  or  sound. 

If  the  OS  is  patulous  a  very  blunt  steel  dilator  like  the  one 
shown  in  Fig.  55  should  be  used  if  one  is  used  at  all,  instead  of 
the  small  flexible  sound.  As  far  as  its  diagnostic  use  is  indica- 
ted, the  length  of  the  uterus,  size  of  the  os,  mobility  and  posi- 
tion may  all  be  ascertained  b}-  digital  and  bimanual  examina- 
tion.    As  regards  its  therapeutical  use,     I  sometimes  use  it  in 


METHOD    OF    EXAMINATION. 


131 


flexions  or  acute  displacements  if  I  have  failed  by  other  methods, 
while  other  displacements  such  as  versions  and  prolapsus  can  be 
corrected  by  the  use  of  the  wire  uterine  repositor  or  manually. 
To  INTRODUCE  the  sound  into  the  uterus,  the  patient  is 
placed  in  the  latero-prone  or  Sims  position  with  the  thighs  well 
up.  The  instrument  is  taken  lightly  by  the  handle  in  the  left 
hand,  while  the  point  of  the  forefinger  of  the  right  hand  is  carried 
up  to  the  OS  uteri,  which  is  felt  and  its  direction  and  the  position 
of  the  uterus  ascertained.  This  is  important  to  know  because  a 
flexion  might  exist  and  unless  the  sound  were  introduced  to  cor- 
respond to  the  bend  the  uterine  wall    might  be  injured.     The 


Fig.  55. — Steel  HDUiid. 

sound,  after  it  has  been  warmed  and  lubricated,  is  introduced 
along  the  finger  with  the  concavity  toward  the  perineal  body  and 
the  handle  directed  backward.  By  following  the  course  of  the 
finger  the  end  of  the  sound  comes  in  contact  with  the  os  uteri, 
and  with  a  little  manipulation  enters  the  cavity  of  the  uterus. 
It  is  then  carried  along  the  cervical  canal  and  the  handle  turned 
with  a  general  sweep  so  as  to  bring  the  concavity  anterior  instead 
of  posterior,  thus  corresponding  to  the  uterine  canal.  It  is  then 
gently  pushed  forward  until  it  reaches  the  fundus  uteri,  which 
is  ascertained  by  a  slight  sense  of  resistance  that  is  felt  to  the 
onward  passage.  If  the  introduction  causes  very  much  pain,  it 
indicates  that  something  is  wrong  and  one  should  withdraw  the 
sound  or  not  introduce  it  at  all.  Again,  in  certain  softened  states 
of  the  uterus,  such  as  metritis  and  subinvolution,  it  would  be 
possible  to  penetrate  the  wall  and  still  cause  very  little  pain. 


132  DISEASES   OF    WOMEN. 

Some  physicians  use  a  speculum,  to  aid  in  the  introduction 
of  the  sound.  By  exposing  the  os  uteri  by  means  of  a  bivalve 
speculum,  the  point  can  be  readily  introduced  into  the  uterus. 
The  speculum  is  in  the  way  if  the  sound  has  to  be  turned,  and 
besides  it  takes  a  longer  time  to  perform  the  operation  than  with- 
out it.  It  has  this  advantage — the  sound  can  be  kept  clean  so 
that  no  infection  will  be  carried  into  the  diseased  uterine  cavity. 

The  usual  difficulties  experienced  in  passing  the  sound  are 
caused  by  stenosis  of  the  canal  or  displacements  of  the  uterus, 
such  as  flexions.  If  the  sound  meets  with  resistance,  it  should 
be  withdrawn  or  slightly  turned;  since  the  diseased  uterine  wall 
may  be  readily  injured  and  perforated;  never  use  force  in  its 
INTRODUCTION.  If  the  patient  is  anxious  for  you  to  use  a  sound, 
be  very  careful  lest  there  be  pregnancy,  the  introduction 
usually  resulting  in  abortion.  As  I  said  before,  its  use  is  contra- 
indicated  in  most  of  the  cases  and  should  not  be  used  indiscrim- 
inately. The  WIRE  UTERINE  REPOsiTOR  invented  by  Dr.  Still 
takes  the  place  of  the  uterine  sound  as  a  therapeutical  agent 
and  should  be  used  if  possible  in  preference  to  the  sound. 

THE  RECTUM.  The  results  obtained  by  vaginal  examina- 
tion are  limited  by  the  fact  that  the  finger  cannot  be  pressed  very 
much  higher  than  the  reflection  of  the  vaginal  walls  which  form 
the  fornices;  although  they  can  be  stretched,  the  finger  in  too 
short  to  reach  very  high.  This  is  partly  overcome  by  the  pres- 
sure of  the  upper  hand  in  performing  the  bimanual,  but  in  other 
cases  in  which  the  bimanual  is  unsatisfactory  and  it  is  not  prac- 
tical to  make  the  vaginal,  rectal  examination  is  substituted. 
Schultze  says:  "To  find  out  some  of  the  anomalous  positions 
of  the  uterus  and  their  causes,  it  is  often  indispensable 
to  palpate  high  up  behind  it,  and  to  do  so  per  vaginam  is  gen- 
erally impossible;  we  can  reach  much  farther  up  on  the  cervix. 


METHOD    OF    EXAMINATION.  133 

even  with  one  finger  in  the  rectum,  than  in  the  vagina.  By 
introducing  two  fingers  up  the  rectum  we  can  reach  across  the 
fundus  uteri,  to  the  fingers  of  the  other  hand,  feeling  through  the 
abdominal  wall,  and  make  a  complete  examination  of  the  whole 
cavity  of  the  pelvis  with  ease  when  this  is  impossible  from  the 
vagina."  (See  Fig.  51.)  In  the  case  of  virgins,  I  usually  make 
the  rectal  examination  first,  and  if  that  is  not  satisfactory,  and 
the  case  does  not  yield  to  treatment,  I  then  make  the  vaginal. 

The  rectum  should  be  emptied,  preferably  by  the  use  of  an 
enema.  The  examiner  should  be  sure  the  finger  nail  is  not  long 
or  rough,  the  mucous  membrane  of  the  rectum  being  highly 
sensitive.  The  finger  should  be  thoroughly  lubricated,  vaseline 
being  best  and  most  commonly  used.  The  pulp  of  the  finger 
should  then  be  placed  against  the  external  sphincter  and 
there  held  an  instant  until  the  resistance  is  overcome;  then  grad- 
ually force  the  finger  forward  and  upward,  noting  the  condition 
of  the  walls,  the  sphincters,  mucous  membrane,  the  presence 
of  piles,  fissures,  ulcers,  etc.  Next  turn  the  pulp  of  the  examin- 
ing finger  so  that  it  lies  on  the  anterior  rectal  wall,  through 
which  can  be  felt  the  cervix.  If  the  uterus  is  in  normal  posi- 
tion this  is  the  only  part  that  can  be  felt  through  the  anterior 
rectal  wall.  By  feeling  on  either  side  of  the  uterus  with  pressure 
on  the  abdomen,  the  ovaries,  tubes  and  ligaments  can  be  detected. 

The  OBJECT  of  the  rectal  examination  is  to  verify  the  bi- 
manual examination,  to  take  the  place  of  the  vaginal  and  to 
locate  cause  of  rectal,  as  well  as  uterine  disorders.  In  cases  of 
displacements  of  the  uterus  the  diagnosis  frequently  depends 
upon  the  rectal  examination.  In  forward  displacements  the 
fundus  is  never  felt  on  rectal  examination,  while  in  backward 
displacements  it  is  always  felt.  In  retro-deviations  some- 
times rectal  treatment  is  given  while  in  the  genu-pectoral  posi- 


134  DISEASES    OF    WOMEN. 

tion  in  the  effort  to  force  the  uterus  forward  into  its  normal 
place.  In  cases  of  chronic  constipation,  prolapsus  of  the  bowel 
or  hemorrhoids,  I  usually  make  a  rectal  examination,  since  the 
cause  of  the  trouble  is  frequently  best  ascertained  in  this  manner. 
Sometimes  the  hemorrhoidal  condition  or  ulceration  is  beyond 
the  reach  of  the  finger  when  examined  in  the  usual  way,  that  is 
in  the  latero-prone  position.  If,  in  such  cases,  the  patient  is 
examined  while  in  the  squatting  posture,  one  can  reach  an 
inch  or  more  higher,  and  the  condition  correctly  diagnosed.  The 
author  has  treated  cases  of  this  sort.  There  were  constrictions 
of  the  bowel,  too  high  to  be  reached  when  the  patients  were 
examined  in  the  lateral  position,  but  by  examining  them  in  the 
above  mentioned  way  the  folds  in  the  bowel  were  reached  and 
with  the  assistance  of  the  external  hand,  by  which  the  bowel 
was  pulled  upward,  completely  removed. 

THE  BLADDER  AND  URETHRA.  The  intimate  vascu- 
lar and  nervous  connection  with,  and  the  proximity  of  the 
uterus  to,  the  bladder,  result  in  symptoms  of  many  uterine  dis- 
eases being  referred  to  the  bladder,  and  in  cases  in  which  the 
bladder  is  affected,  it  is  sometimes  necessary  to  make  an  exami- 
nation of  that  organ,  which  is  accomplished  principally  by  pal- 
pation. Disturbance  of  micturition,  such  as  pain  at  or  just 
following  the  completion  of  the  act,  inability  to  retain  the 
urine  or  frequent  micturition,  involuntary  escape  of  urine 
on  coughing  or  other  exertion,  feeling  of  weight  and  discom- 
fort over  the  pubes,  backache  early  in  the  morning  before  evac- 
uation of  the  bladder,  changes  in  the  urine,  such  as  the  pres- 
ence of  pus,  triple  phosphates  or  marked  acidity,  and  the  pres- 
ence of  tenderness  just  above  the  symphysis  pubis,  Indicate  cys- 
titis or  some  other  form  of  bladder  trouble.  Such  symptoms, 
primarily  indicate,  in  many  cases  some  form  of  uterine  trouble 


METHOD    OF    EXAMINATION.  135 

especially  metritis,  the  bladder  disturbances  being  secondary. 
Various  instruments  have  been  invented  for  the  purpose  of  ex- 
amining the  inside  of  the  bladder,  but  I  regard  them  as  useless 
in  most  of  the  cases  in  which  they  are  used,  and  in  many,  posi- 
tively injurious  since  incontinence  of  urine  often  follows  as  a 
result  of  dilatation  of  the  urethra,  which  is  necessary  in  instru- 
mental examination  of  the  bladder.  The  bladder  is  a  closed 
viscus  and  should  be  left  severely  alone  and  no  instruments  in- 
troduced, except  in  cases  of  calculi  in  the  bladder  or  reten- 
tion OF  urine,  in  which  latter  case  a  catheter  should  be  used  to 
relieve  the  distention. 

In  enlargement  of  the  bladder  from  retention  of  urine  there 
exists  a  rounded  tumor  above  the  symphysis,  which  can  be  seen 
as  well  as  palpated.  Pressure  on  it  produces  a  desire  to  mic- 
turate. Percussion  aids  in  diagnosis,  a  dull  note  being  elicited. 
Cystocele  can  also  be  determined  by  palpation  as  well  as  inspec- 
tion. Sensitive  points  in  the  urethra  and  often  calculi  of  bladder 
can  be  diagnosed  by  palpation  through  the  anterior  vaginal  wall. 
If  the  calculi  are  very  large  the  diagnosis  is  comparatively  easy. 

In  cases  of  vaginismus  or  stenosis  of  the  vagina  from  any 
cause,  copulation  may  take  place  in  the  urethra.  The  writer 
saw  one  case  of  this  kind.  The  urethra  had  become  so  elastic 
that  complete  contraction  followed  the  copulative  act,  and  there 
was  no  dribbling  of  urine  or  other  bladder  disturbances.  A 
local  urethritis  is  sometimes  formed  in  cases  in  which  a  cystitis 
or  acidity  of  the  urine  exists.  This,  along  with  prolapsus  of 
the  urethral  mucous  membrane,  polypi  and  urethra  caruncles 
which  are  vascular  growths  at  the  meatus  urinarius,  can  be  diag- 
nosed by  inspection.  In  such  conditions  there  is  marked  pain 
on  micturition  which  is  often  referred  to  the  urethra,  perineum 
or  spine. 


136  DISEASES     OF    WOMEN. 

EXAMINATION  OF  THE  PELVIS.  In  making  an  examina- 
tion of  the  pelvis  and  lower  dorsal  region,  first  use  inspection. 
I  usually  have  the  patient  sit  on  the  edge  of  the  table  with  her 
back  to  me.  After  raising  the  garments  so  as  to  expose  the  back, 
first  notice  the  median  furrow,  its  depth,  whether  flattened, 
deepened  or  widened,  and  its  direction.  If  furrow  is  deepened 
it  indicates  an  anterior  condition  of  the  spine  or  an  atrophied 
condition  of  the  erector  spin ae  muscles  which  form  the  walls  of 
the  median  furrow;  if  flattened  or  obliterated,  a  posterior  con- 
dition ;  if  direction  is  changed,  it  indicates  a  scoliosis  or  lateral 
curvature.  If  the  spines  are  very  much  posterior,  especially 
in  the  lumbar  region,  the  skin  covering  them  will  be  discolored, 
usually  a  yellowish  brown.  This  is  probably  the  result  of  pres- 
sure on  the  spine  resulting  from  the  patient  leaning  against  the 
back  of  a  seat. 

In   examining  the  patient  in  the  sitting  posture  let  her  sit 
naturally;  that  is,  do  not  tell  her  to  sit  erect  or  bend  forward, 

the  WEAK  POINTS  SHOWING  BEST  WHILE  SHE  SITS  IN  HER  NATURAL 

POSITION.  If  the  patient  does  not  sit  as  she  ordinarily  does, 
the  STRAINED  CONDITION  of  the  muscles  obliterates  some  of  the 
weak  parts.  Compare  the  two  innominate  bones,  notice  if  one 
is  higher  or  more  prominent  than  the  other,  the  full  side  usually 
indicating  the  affected  or  diseased  side.  (See  Fig.  44.)  Note 
the  PROMINENCE  and  CURVE  of  the  sacrum  and  the  posterior  spines 
of  the  ilium,  also  the  crease  between  the  buttocks,  whether  it  is 
straight  or  deflected  to  one  side;  note  also  the  size  of  the  buttocks 
since  the  condition  of  the  glutei  muscles  indicates,  in  a  meas- 
ure, the  condition  and  activity  of  the  genitalia.  This  is  best 
illustrated  in  women  who  have  been  married  a  short  while,  the 
hips  having  become  broadened  and  enlarged.  Note  the  con- 
cavity OF  THE  waist  line,  the  two  sides  seldom  being  alike.     The 


METHOD    OF    EXAMINATION.  137 

deeper  or  more  abrupt  the  curve,  the  higher  the  mnominate, 
but  if  the  fossa  or  curve  is  shallow  and  increased  in  length,  that 
side  of  the  pelvis  is  lower  than  the  opposite  one,  or  the  patient 
has  a  lateral  spinal  curvature  to  that  side.  Note  the  inclina- 
tion of  the  sacrum  and  the  effect  on  the  spinal  column,  whether 
abnormally  curved  forward  or  whether  flattened,  thus  indicat- 
ing an  absence  of  the  normal  curve.  Now  place  the  patient  in 
the  dorsal  position;  compare  the  anterior  superior  spines  of  the 
ilia,  their  height  and  prominence.  Note  the  length  of  the 
limbs;  it  is  best  not  to  pull  or  stretch  first  one  limb  then  the 
other,  to  ascertain  their  length,  but  to  let  the  patient  lie  naturally 
on  the  table.  Slight  shortening  in  recent  cases  indicates 
an  innominate  lesion;  slight  lengthening,  hip  disturbances; 
probably  a  partial  dislocation. 

PALPATION.  In  palpating  the  pelvis,  I  usually  first  sit 
behind  the  patient,  she  either  sitting  or  standing.  By  placing 
both  hands  on  the  crest  of  the  innominate  bones,  height  and 
prominence  can  be  best  ascertained.  Ask  the  patient  if  she  has 
to  pad  her  dress  on  one  hip  or  if  she  notices  one  side  being  higher 
than  the  other;  frequently  the  patient  discovers  this  in  having 
a  dress  fitted.  The  posterior  spines  should  be  compared  as  to 
their  height,  distance  apart  and  prominence,  also  the  dif- 
ferent parts  of  the  sacrum  be  outlined.  Feel  for  irregularities 
at  the  different  articulations,  and  especially  at  the  sacro-iliac 
synchondrosis.  A  knotted  or  lumpy  condition  can  be  felt  at 
this  point  in  a  great  man}-  cases,  and  is  indicative  of  pelvic  dis- 
ease and  a  subluxated  innominate.  This  thickening  is  probably 
the  result  of  an  enlargement  of  the  lymphatic  glands,  or  of  the 
escape  of  synovia  from  the  sacro-iliac  articulation.  Note  the 
condition  of  the  fifth  lumbar,  whether  displaced  or  a  tender- 
ness   exists;    either    one    indicating    pelvic    trouble.     Put   some 


138  DISEASES    OF   WOMEN. 

PRESSURK  over  the  sciatic  nerve  at  a  point  immediately  behind 
the  trochanter,  it  being  tender  in  nearly  all  cases  of  pelvic 
inflammation. 

Now  turn  the  patient  to  the  dorsal  position,  then  by  placing 
the  hands  on  the  crests  of  the  ilia,  note  their  height,  distance 
apart  of  spines,  direction  and  amount  of  flare  of  crest  and  whether 
or  not  a  tenderness  at  any  point  exists.  Note  where  crests 
would  meet  if  extended.  They  normally  meet,  if  extended,  in 
the  median  line  about  half  way  between  pubes  and  knees.  If 
they  meet  to  one  side  a  lesion  is  usually  the  cause,  it  being  a 
slight  twist  or  rotation  of  one  innominate  or  in  some  cases  a 
twist  of  the  pelvis  on  the  fifth  lumbar  vertebra.  Compare  the 
muscles  attached  just  below  the  crest;  perhaps  one  side  is  full^ 
the  other  shrunken.     The  full  side  is  more  often  the  diseased  one. 

Examine  the  symphysis  pubis  for  irregularities  or  tender- 
ness, either  one  indicating  a  displaced  innominate.  Turn  the 
patient  on  her  side  and  examine  the  lumbar  region  and  especially 
the  lumbo-sacral  articulation  for  displacements  and  tenderness. 
I  reh^  a  great  deal  upon  the  location  of  the  tender  spots,  they 
indicating  something  abnormal;  if  in  a  joint,  a  displacement;  if 
in  a  muscle,  an  abnormal  contraction  or  contracture.  This  is 
especially  true  in  acute  cases  and  the  location  of  the  tenderness 
is  indicative  of  the  organ  affected.  In  chronic  cases  soreness  does 
not  always  exist  when  there  is  a  displacement,  hence  its  ab- 
sence does  not  necessarily  negate  a  lesion,  but  in  acute  cases  it 
always  exists  and  furnishes  the  best  means  for  diagnosis. 

In  connection  with  the  examination  of  the  pelvis,  palpate 
the  lower  ribs,  note  their  obliquity,  the  intercostal  spaces  and 
points  of  tenderness,  their  displacement  often  causing  ovarian 
or  kidney  disturbances  of  some  sort.  Hystero-epilepsy  some- 
times results  from  lesions  of  these  ribs.     In  palpating  the  ribs. 


METHOD    OF    EXAMINATION.  139 

it  is  best  to  do  it  while  the  patient  is  sitting.  The  operator,  sit 
ting  or  standing  behind  the  patient,  places  the  hands  on  the 
lower  ribs  and  compares  the  two  sides  at  the  same  time;  devia- 
tions being  more  readily  found  in  this  way. 


140  DISEASES   or   WOMEN. 


DISEASES  OF  THE  VULVA. 


VULVITIS.  Vulvitis  is  defined  as  an  inflammation  of  the 
vulva,  this  comprising  inflammation  of  the  greater  and  lesser 
lips,  vestibule,  clitoris,  or  any  part  of  the  external  genitals.  In 
order  to  understand  vulvitis  it  is  necessary  to  know  what  inflam- 
mation is,  the  changes  taking  place,  symptoms  and  termina- 
tion. 

Inflammation  may  be  defined  as  an  effort  on  the  part 
OF  the  organism  to  rid  itself  of  some  toxic  element,  or 
overcome  an  injury.  This  toxic  element  may  be  introduced  from 
without,  such  as  irritating  discharges  or  gonorrheal  poison- 
ing; or  it  may  arise  from  within  from  stagnated  blood,  which  has 
undergone  certain  changes.  There  is  congestion,  arterial  if 
acute,  venous  if  chronic,  which  gives  rise  to  heat,  redness, 
SWELLING,  PAIN  and  disturbance  of  function,  if  the  inflamma- 
tion is  a  typical  one. 

In  treating  inflammation  it  is  necessary  to  know  which  of 
these  causes  are  operating,  since  upon  this  depends  the  cure. 

There  are  various  forms  of  inflammation  of  the  vulva,  they 
being  classified  according  to  their  severity,  and  usually  divided 
into  simple,  gonorrheal,  follicular  and  phlegmonous.  In  the 
simplest  form  we  find  the  catarrhal  inflammation,  while  in  cases 
in  which  there  exists  a  great  deal  of  toxic  matter,  it  is  called  the 
phlegmonous  type. 

The  cause  of  vulvitis  may  depend  upon  lack  of  cleanliness,  col- 
lection of  dirt  or  smegma ;  the  patient  not  cleansing  herself  properly 


DISEASES    OF   THE   VULVA.  141 

after  menstruation.  This  foreign  or  toxic  matter  gets  into  the 
folds  of  the  vulva,  first  causing  irritation  and  finally  resulting 
in  inflammation.  More  or  less  exfoliation  of  the  epithelium 
takes  place,  leaving  the  parts  raw,  while  patches  of  erosion  and 
ulceration  occasionally  occur.  In  obese  people,  the  friction 
of  the  vulva  produced  by  walking,  especially  in  warm  weather, 
tends  to  irritate  the  parts,  leaving  them  in  an  inflamed  state. 

Irritating  or  toxic  discharges  such  as  a  chronic  leucorrhea, 
a  cancerous,  gonorrheal,  acid  vaginal  or  uterine  secretion,  and 
INCONTINENCE  of  urine  are  common  causes  of  vulvitis.  The 
source  of  most  of  these  discharges  is  a  diseased  uterus  or  vagina. 
Endometritis,  ulceration  of  the  cervix,  or  even  simple  conges- 
tion or  catarrh  of  the  above  organs  produce  it.  Diabetes  and 
acid  urine  set  up  a  pruritus  which  often  terminates  in  an  inflam- 
mation of  the  vulva.  In  children  the  oxyuris  or  thread  worm 
may  migrate  from  the  rectum,  setting  up  a  pruritus  which  re- 
sults in  the  patient  scratching  the  part  in  her  efforts  to  obtain 
relief,  leaving  it  red  and  swollen.  From  this  results  chronic 
pruritus  vulvae,  or  itching  of  the  vulva.  Traumatism,  such  as 
falls  astride  a  sharp  object,  blows,  rape  and  awkward  coitus,  pro- 
duce vulvitis.  On  account  of  the  character  of  the  tissues  com- 
posing the  vulva,  vulvitis  from  trauma  is  hard  to  cure.  In 
one  case  treated  by  the  author  an  abscess  developed  within 
a  few  days  from  a  bruise  received  from  a  fall  on  the  sharp  comer 
of  a  chair. 

Gonorrhea  is  given  as  a  cause  of  vulvitis  in  two-thirds 
of  all  cases.  This  per  cent,  is  high,  but  not  too  Ifigh  for  the 
lower  classes  of  people,  in  which  this  disease  is  oftenest 
found.  The  disease  in  such  people  is  not  properly  treated  and 
parts  not  kept  clean.  On  account  of  this  and  the  character  of 
secretions,  the  labia  are  red  and  inflamed  during  the  entire  course 


142  DISEASES    OF    WOMEN. 

of  the  disease.  This  form  of  vulvitis  is  discussed  under  the  head 
of  specific  vaginitis. 

Sometimes  pregnancy  produces  a  swelling  of  the  vulva 
accompanied  by  a  severe  itching,  which  in  turn  sets  up  an  inflam- 
mation, but  this  is  unusual.  In  parturition,  occasionally  the 
vulva  is  bruised  resulting  in  inflammation,  especially  in  cases 
in  which  the  external  genitals  are  very  small  or  if  instruments 
are  used. 

Vulvitis  due  to  friction  in  walking  involves  the  greater  lips; 
from  masturbation,  the  lesser  lips,  clitoris  and  vestibule;  from 
rape  or  awkward  coitus,  the  hymen,  lesser  lips,  urethra  and  an- 
terior vaginal  walls;  from  trauma,  the  greater  lips;  and  from 
irritants,  the  ostium  vaginae  and  nymphae.  Lesions  found 
as  a  cause  of  most  cases  of  vulvitis  not  specific,  are  usually  a  slipped 
innominate  or  a  subluxated  lumbar  vertebra;  these  affecting  the 
vaso-motor  nerve  supply  to  the  part.  The  vaso-motor  nerves 
are  derived  indirectly  from  the  hypogastric  plexus  and  follow 
the  blood  vessels  to  the  vulva.  This  plexus  is  in  relation  with 
the  sacro-iliac  synchondrosis  and  is  aflfected  whenever  the  in- 
nominates  are  forced  out  of  place,  even  though  it  be  slight.  If 
the  case  is  not  one  of  traumatic  or  specific  origin  the  cause  should 
be  sought  elsewhere  than  in  the  vulva  itself.  A  uterine  dis- 
placement results  in  an  abnormal  acrid  discharge  and  still  back 
of  this  is  the  primary  cause,  the  disturbance  of  the  bony  frame- 
work which  encloses  the  pelvic  viscera. 

The  menopause  is  often  accompanied  by  a  "breaking  out" 
on  the  vulva.  This  eruption  causes  an  itching  which  is  the  only 
noticeable  symptom  in  most  cases. 

The  symptoms  of  vulvitis  are  those  of  inflammation;  that 
is,  heat,  redness,  swelling,  pain  and  disturbance  of  function; 
the  severity  of  the  symptoms  depending  on  the    degree  of  the 


DISEASES    OF    THE    VULVA.  143 

disease.  In  acute  types  there  is  marked  heat,  the  parts  are  very 
red  and  angry  in  appearance  and  the  pain  is  constant.  In  the 
MILDER  cases  heat  is  less  noticed,  the  parts  are  only  slightly  red 
dened  and  pain  occurs  at  irregular  intervals.  On  account  of 
the  congested  condition,  there  is  a  hypersecretion  of  mucus, 
which  in  children  is  often  of  a  sticky  nature  and  tends  to  the 
formation  of  adhesions,  such  as  an  acquired  hooding  of  the  cli- 
toris. In  other  cases  pus  is  discharged,  but  this  occurs  to  an  ap 
preciable  extent  only  in  the  very  marked  cases,  such  as  the 
phlegmonous  type.  In  simple  cases  the  discharge  is  serous  or 
muco-purulent  and  is  usually  abundant,  the  amount  being 
determined  by  the  degree  of  congestion.  If  it  is  purulent,  vari- 
ous micro-organisms  can  be  found,  their  presence  being  a  result 
rather  than  a  cause  of  the  disease.  It  is  accompanied  by  a 
certain  amount  of  pruritus  of  the  vulva,  especialh'  when  the 
inflammation  begins  to  recede  and  the  secretions  to  dessicate. 
Often  the  habit  of  masturbation  is  contracted  in  relieving  the 
itching,  which  habit  when  so  formed  is  very  hard  to  overcome. 
On  the  other  hand  masturbation  may  cause  vulvitis.  Mont- 
gomery says:  "The  production  of  vulvitis  in  the  virgin  by  mas- 
turbation is  recognized  by  finding  the  smaller  labium  and  the 
space  between  it  and  the  hymen  covered  with  small  pointed 
excrescences ;  the  nymphae  elongated ;  the  clitoris  or  its  prepuce 
irritated;  swelling  of  the  shallow  groove  between  the  orifice  of 
the  urethra  and  the  clitoris;  clear,  abundant  secretion  from  the 
duct  of  Bartholin's  glands;  abnormal  sensibility;  exaggerated 
prudery;  and  distinct  hysterical  phenomena." 

Sometimes  there  is  edema  of  the  vulva  in  cases  of  vulvitis, 
especially  if  it  depends  upon  pregnancy  as  the  cause.  Micturition 
is  interfered  with,  it  usually  being  frequent,  painful  and  im- 
perfect, or  the  inflammation  in  its  early  stages  may  entirely 


144  ,  DISEASES    OF   WOMEN. 

OCCLUDE  THE  URETHRAL  orifice,  resulting  in  the  retention  of  the 
urine.  The  neighboring  glands,  Bartholin's  in  particular,  are 
swollen,  congested  and  a  hypersecretion  is  fairly  constant.  In 
the  follicular  type  the  hair  bulbs  and  sebaceous  glands  are  swollen, 
these  being  the  seat  of  the  disease.  The  tissue  between  these 
hair  follicles  and  glands  is  apparently  healthful,  thus  giving  the 
diseased  area  a  mottled  appearance.  These  follicles  continue 
to  increase  in  size  until  they  burst,  after  which  they  soon  shrivel 
and  dry  up.  During  the  period  in  which  the  enlargement  of 
the  follicle  is  greatest,  a  drop  of  pus  can  be  expelled  by  pressure 
on  it. 

The  treatment  depends  upon  the  cause  that  is  found  in  the 
individual  case.  If  the  inflammation  is  severe,  some  emollient 
application  should  be  used  merely  as  a  palliative  agency  to  re- 
lieve the  heat  and  burning.  The  part  should  be  kept  clean 
and  should  be  washed  wHh  some  mild  antiseptic  solution  such 
as  boracic  acid  solution.  If  there  are  bony  displacements  which 
are  to  blame  for  the  trouble,  they  should  be  treated.  The  blood 
suppl}'  should  be  controlled,  if  possible,  this  being  done  to  a 
certain  extent  by  treatment  applied  to  the  lower  lumbar  region. 
If  there  is  a  mechanical  obstruction  to  the  venous  return,  such 
as  a  displaced  uterus  or  prolapsed  bowels,  this  should  be  cor- 
rected. When  pregnancy  is  the  cause  a  cure  is  not  probable 
until  after  parturition.  If  the  inflammation  is  of  venereal  ori- 
gin, the  application  of  a  rose  colored  solution  of  permanganate 
OF  POTASSIUM  is  beneficial,  sometimes  even  destroying  the  gon- 
orrheal germs,  it  being  a  germicide.  If  it  is  a  very  bad  form  of 
inflammation,  the  patient  should  be  kept  as  quiet  as  possible 
to  prevent  friction  and  irritation  of  the  part,  this  coupled  with 
the  correction  of  the  various  lesions  found,  has  yielded  nice  re- 
sults in  the  author's  practice. 


DISEASES    OF   THE    VULVA.  145 

DISEASE  OF  BARTHOLIN'S  GLANDS.  Diseases  of  Bar- 
tholin's glands,  especially,  those  not  inflammatory  in  character, 
are  seldom  seen  before  the  age  of  seventeen  or  after  the  age  of 
forty-five,  the  disturbances  therefore  occurring  during  the  years 
in  which  the  sexual  function  is  most  active.  Their  causes 
depend  upon  incidents  connected  with  the  sexual  functions 
such  as  excessive  or  violent  intercourse,  masturbation  or  ac- 
cidents of  pregnancy  or  labor. 

The  inflammatory  disturbances  of  these  glands  are  seldom 
primary,  but  occur  as  complications  of  vulvitis  or  vaginitis, 
especially  the  gonorrheal  variety.  In  cases  in  which  the  glands 
are  temporarily  enlarged  from  congestion,  there  is  a  hypersecre- 
tion of  a  glairy  fluid  and  is  one  of  the  sources  of  the  discharge 
in  leucorrhea.  Their  function  is  to  secrete  a  mucus  which 
lubricates  the  external  genitals ;  this  is  most  marked  during  sexual 
excitement.  There  is  no  emission  in  the  female,  only  a  hyper- 
secretion, this  coming  principally  from  Bartholin's  glands. 
Sometimes  erotic  dreams  cause  this  hypersecretion,  especially 
if  the  glands  are  congested  and  irritable.  By  placing  the  finger 
over  the  duct  and  pressing  up  and  back,  the  enlarged  gland  can 
be  felt ;  the  causes  which  produce  hypersecretion  leading  also  to 
its  enlargement.  The  orifice  of  the  duct,  which  is  located  on 
the  inner  posterior  aspect  of  the  middle  portion  of  the  lesser  lip, 
is  surrounded  by  a  red  areola,  giving  it  the  appearance  of  the 
bite  of  an  insect. 

Affections  of  Bartholin's  glands  interfere  with  sexual  inter- 
course since  the  discharge,  or  rather  hypersecretion,  comes  from 
these  glands  and  in  cases  of  loss  of  sexual  desire  these  glands 
are  usually  atrophied.  When  there  is  increased  sexual  desire, 
the  glands  are  large  and  irritable,  even  psychic  influences  causing 
a  discharge  of  mucus.     It  is  the  analogue  of  Cowper's  gland  in 

10 


146  DISEASES    OF    WOMEN. 

the  male,  its  function  being  similar,  that  is,  it  secretes  a  lubri- 
cant. In  cases  in  which  tonicity  of  the  vaginal  walls  and  vulva, 
is  lost,  Bartholin's  glands  are  usually  found  to  be  diseased  and 
leucorrhea  forms  one  of  the  symptoms.  One  has  said  that  a 
flabby,  pendulous  condition  of  the  abdomen  results  from  affec- 
tions of  Bartholin's  glands. 

In  difficult  labor  dependent  upon  a  rigid  cervix  and  vagina 
the  "Old  Doctor"  has  advised  inhibition  of  these  glands, 
this  helping  dilatation  of  the  os  uteri  And  vagina. 

When  the  duct  is  occluded  it  causes  retention  of  the  secre- 
tion, thus  forming  a  cyst.  This  is  diagnosed  from  hernia  by  its 
position,  shape,  size  and  fluctuation.  Often  an  enlargement 
of  this  gland,  varying  in  size  from  that  of  an  ordinary  marble 
to  that  of  an  orange,  results  from  a  strain  or  slip  of  the  innom- 
inate bone  on  the  same  side.  The  author  has  treated  several 
cases  of  this  sort,  the  swelling  coming  on  within  a  few  hours 
after  the  accident.  Sexual  intercourse  aggravates  the  trouble 
and  usually  by  the  time  the  patient  consults  a  physician,  the 
swelling  is  considerable.  The  correction  of  the  innominate 
lesion  is  sufficient  in  such  cases  to  effect  a  cure.  The  accident 
results  from  a  twist  of  the  body  or  a  fall,  the  patient  slipping  on 
an  icy  pavement,  or  due  to  strain  resulting  from  the  attempt  to 
recover. 

Abscesses  sometimes  form  in  this  gland  and  should  be  treated 
according  to  the  rules  of  surgery.  In  the  treatment  of  the  dis- 
eases affecting  this  gland,  remove  the  sources  of  irritation  and 
direct  the  work  to  remove  obstructions  to  the  venous  drainage 
in  order  to  relieve  the  congestion.  There  should  be  complete 
rest  of  the  gland,  sexual  intercourse  being  forbidden.  Fre- 
quently uterine  or  vaginal  troubles,  such  as  loss  of  tonicity,  are 
the  primary  causes  and  in  such  cases  the  treatment  should  be 


DISEASES    OF    THE    VULVA. 


147 


directed  to  those  organs.  Manipulation  over  and  around  the 
gland  is  beneficial  and  especially  so  in  cases  of  congestion.  Cysts 
of  this  gland  can  be  reduced  by  opening  up  the  duct  with  a  probe 
or  by  direct  manipulation  over  the  part,  by  which  the  contents 


Fit;  5().  — Diptention  of  the   rijj^lit    viilvo-viiginal  >^laii(l 
with  pus.     (B.vforrt). 

of  the  cyst   are  forcibly  expelled. 

PRURITUS  VULV.'VE.  This  affection  consists  of  an  irrita- 
bility of  the  nerves  supplying  the  vulva  which  gives  rise  to  an 
INTENSE  ITCHING  and  burning  of  the  part.  The  regions  affect- 
ed are   the  inner   side  of  the   labia  ma.jora,  the  labia   minora 


148  DISEASES   OF   WOMEN. 

and  the  clitoris.  In  some  cases  it  may  extend  to  the  mons 
Veneris,  anus  and  the  inner  sides  of  the  thighs.  It  is  not  a  dis- 
ease but  a  symptom,  hence  the  curative  treatment  should  not 
be  directed  entirely  to  the  parts  affected,  but  to  the  cause.  This 
irritation  is  either  at  the  peripheral  or  spinal  end  of  the  nerve, 
that  is,  a  local  irritation  or  a  referred  impulse. 

The  irritation  at  the  spinal  end  is  the  result  of  an  impinge- 
ment or  disturbance  of  nutrition  of  the  deep  origin  of  the  nerve, 
in  other  words  is  due  to  a  bony  lesion  pressing  on  the  nerve  at  its 
exit,  or  along  its  course,  or  on  the  blood  vessels  supplying  the 
nerve  or  its  cells  with  nutrition. 

Another  cause  of  this  affection  is  dirt  or  the  accumulation 
of  smegma  after  menstruation,  and  sometimes  the  disease  is 
due  to  the  oxyuris  or  threadworm  which  has  migrated  from  the 
rectum  to  the  vulva.  Pediculi  pubis  form  an  important  cause 
in  the  lower  classes.  The  "crabs",  as  they  are  commonly  called, 
burrow  deeply  in  the  mons  ^^eneris,  thereby  setting  up  a  severe 
pruritus,  or  in  some  cases,  a  well  developed  inflammation,  if 
the  patient  scratches  the  part  very  violently,  as  is  often  the  case. 
Sometimes  pessaries  are  the  cause,  especially  if  they  are  ill  fitted; 
they  irritate  the  vaginal  wall  and  cause  a  perverted  or  a  markedly 
acid  secretion.  In  vulvitis,  especially  during  the  healing  state,. 
there  exists  a  certain  amount  of  itching,  this  indicating  that  the 
part  is  healing.  Diabetes,  a  very  important  cause,  results  in 
pruritus  on  account  of  the  irritating  material  found  in  the  urine 
which  is  deposited  around  the  meatus  and  in  the  vestibule,  giving 
rise  to  a  local  irritation.  Any  form  of  irritating  deposit  in  the 
urine  or  an  acid  condition  of  the  urine,  as  found  in  acute  rheuma- 
tism, may  cause  the  itching.  Abnormal  discharges  from  the 
vagina,  such  as  leucorrhea,  is  a  common  cause,  especially  if  it  is  a 
chronic  form  and  the  secretion  has  partly  desiccated.     The  dis- 


DISEASES    OF   THE    VULVA.  149 

charges  from  a  cancerous  condition  will  also  produce  irritation 
which  gives  rise  to  itching. 

Frequently  at  the  menstrual  time  or  immediately  before  or 
after  it,  the  patient  will  complain  of  itching  of  the  vulva,  and 
in  some  cases  it  is  almost  unbearable.  The  writer  had  a  case  re- 
cently of  this  kind  which  could  only  be  relieved  bj'^  a  vaginal 
douche  as  hot  as  could  be  borne.  Congestion  of  the  vulva  will 
usually  give  rise  to  the  itching,  this  congestion  frequently  being 
the  result  of  pregnancy.  Itching  often  accompanies  the  meno- 
pause, or  even  old  age,  giving  rise  to  various  nervous  symptoms. 
Reflexly  it  may  result  from  intestinal  irritation,  diseases  of  the 
rectum,  such  as  hemorrhoids,  diseases  of  the  uterus  with  its 
appendages  and  the  urethra.  To  the  osteopath  the  lesions  found 
in  the  region  of  the  fifth  lumbar  are  the  most  important.  Also 
lesions  found  at  the  junction  of  the  sacrum  with  the  ilium,  that 
is,  subluxations  of  the  sacrum  or  innominate,  disturb  the  nutri- 
tion of  the  parts,  thus  setting  up  a  disturbance  in  the  sacral 
nerves. 

The  pathology  of  the  disease  is  practically  unknown.  One 
observer  mentions  that  many  of  the  nerves,  when  traced  from 
the  deeper  parts  toward  their  termination,  were  seen  to  acquire 
a  dense,  fibrous  character,  some  appearing  as  well  marked  fibrous 
cords,  the  nerve  fibers  being  compressed  or  destroyed.  This 
applies  only  to  the  chronic  cases. 

This  trouble  is  similar  to  pruritus  ani  or  itching  piles; 
the  two  are  sometimes  found  in  the  same  subject,  the  lesions 
being  almost  the  same  in  the  two  affections.  In  the  beginning 
the  irritability  is  very  slight  and  annoys  the  patient  very  little, 
sometimes  existing  only  after  exertion  in  warm  weather,  upon 
exposure  to  artificial  heat  or  during  menstruation.  The  rubbing 
or  scratching  of  the   part  aggravates  the  trouble  rendering  the 


150  DISEASES    OF    WOMEN. 

skin  tender  and  the  nerves  more  sensitive.  As  the  disease  pro 
gresses  the  irritation  increases,  the  patient  is  bereft  of  sleep  at 
night,  avoids  society  and  becomes  melancholic;  sometimes  the 
affection  even  terminating  in  insanity.  On  account  of  loss  of 
sleep,  the  nervous  system  is  affected,  nervous  prostration  some- 
times ensuing.  In  children,  masturbation  frequently  follows, 
which  habit  in  the  young  is  hard  to  break.  In  adults  it  leads  to 
frequent  coitus,  even  rendering  the  patient  hysterical  or  nympho- 
maniacal. On  palpation,  tenderness  is  found  at  the  fifth  lumbar 
sometimes  radiating  over  the  hip  bones. 

In  TREATING  this  affection,it  is  necessary  to  find  the  primary 
cause  of  the  disorder.  If  due  to  external  irritation,  such  as  an 
accumulation  of  filth,  leucorrhea,  acrid  discharges  or  parasites, 
remove  the  source  of  irritation  by  thoroughly  cleansing  the  parts. 
In  case  of  pediculi  pubis,  or  lice,  which  are  lodged  in  the  mons 
Veneris,  thoroughly  anointing  the  affected  area  with  mercurial 
or  sulphur  ointment  is  sufficient  to  cause  the  death  of  the  para- 
site. As  a  rule,  in  the  ordinary  cases  of  pruritus,  local  applica- 
tions do  very  little  good  because  they  do  not  reach  the  cause  of 
the  trouble.  In  some  such  cases,  as  those  due  to  discharges, 
applications  are  of  value.  The  best  applications  in  the  author's 
hands  are  carbolic  acid,  witch  hazel  and  plain  hot  water  or  hot 
compresses.  A  weak  carbolized  solution  is  probably  the  best  of 
all.  In  cases  due  to  pin  worms  a  rectal  injection  of  lime  water 
is  good.  The  "Old  Doctor"  has  advised  the  application  of  an 
ointment  of  lard  and  turpentine  in  such  cases.  The  diet  is  im- 
portant in  cases  due  to  liver  or  kidney  diseases.  Alcohol 
and  spiced  food  should  be  excluded.  Treatment  over  the  sacrum 
and  fifth  lumbar,  correcting  such  lesions  as  are  found,  is  the  most 
satisfactory  method  of  dealing  with  this  trouble  in  cases  in 
which  the  pruritus  is  not  due  to  local  changes  or  causes. 


DISEASES    OF    THE    VULVA.  151 

KRAUROSIS  VULVAE  is  a  term  applied  to  the  condition 
in  which  the  lesser  lips  are  atrophied,  Avith  hardening  of  the  mucous 
membrane  and  skin  of  the  vulva.  At  first  the  parts  are  inflamed 
in  appearance,  there  being  small  red  spots  or  streaks  of  dilated 
arterioles  which  radiate  from  the  center  of  the  nymphae.  These 
disappear  as  the  disease  progresses  and  atrophy  advances.  There 
is  loss  of  sexual  desire ;  w^hether  the  cause  or  result  of  the  atrophy, 
is  unknown. 

The  cause  of  this  condition  is  unknown,  not  even  a  good 
theoretical  explanation  being  offered  by  the  medical  authori- 
ties. The  writer  has  seen  only  a  limited  number  of  cases.  In 
all  of  them  there  was  a  very  rigid  lumbar  spine  with  muscular 
contractures.  In  some  of  these  cases  an  innominate  lesion  was 
discovered. 

Pruritus  is  one  of  the  most  constant  symptoms,  along  with  a 
dry  condition  of  the  parts,  with  a  tendency  to  crack  and  bleed 
on  coitus  or  digital  examination. 

In  the  cases  treated  by  the  author,  work  was  directed  to  the 
innominate  and  lumbar  lesions.  The  cases  were  benefited  and 
one  case  almost  entirely  cured. 

VARICOSE  VEINS  OF  THE  VULVA.  A  varicose  vein  is 
one  that  has  been  distended  to  an  extent  or  for  such  a  length  of 
time,  that  a  part  or  all  of  the  elasticity  of  the  walls  has  been 
destroyed.  The  distention  is  due  to  obstruction  of  the  venous 
return  or  a  paresis  of  the  muscle  fibers  in  the  walls  of  the  veins. 
In  case  of  varicose  veins  of  the  vulva,  the  engorgement  is  due  to 
obstruction  of  the  veins  draining  the  vulva,  this  obstruction 
usually  being  caused  by  pregnancy.  The  parts  affected  are  the 
bulbs  of  the  vagina  and  the  labia  majora.  Sometimes  these 
bulbs  are  enlarged  and  can  be  readily  felt  on  palpation.  This 
gives  rise  to  a  swelling  of  the  vulva  attended  by  a  hypersecretion. 


152  DISEASES    OF   WOMEN. 

The  treatment  consists  of  removing  the  obstruction  and  if 
due  to  pregnancy,  little  can  be  done  until  after  parturition.  If 
due  to  enteroptosis,  the  intestines  should  be  drawn  upward, 
allowing  the  blood  to  drain  from  the  vulva.  Often  rectal  and 
uterine  congestion  so  obstruct  the  blood  that  the  veins  of  the 
vulva  become  varicosed,  since  there  is  a  very  free  anastomosis 
of  all  these  veins.  Strong  treatment  in  the  back  frequently  helps 
the  condition  by  strengthening  the  vaso-motor  supply  to  the 
part. 

There  are  various  other  affections  of  the  vulva,  but 
only  their  names  will  be  given  on  account  of  their  scarcity.  The 
writer  saw  a  case  of  atrophy  of  the  greater  lips  accompanied 
by  hypertrophy  of  the  lesser  in  a  subject  which  was  the  victim 
of  masturbation.  Elephantiasis  is  found  in  tropical  countries 
but  is  rare  in  this  country.  Tumors,  such  as  a  fibroma,  lipoma 
and  rarely  carcinoma,  have  been  found  affecting  the  vulva. 

Once  in  a  while  a  condition  called  a  hooded  clitoris  is  found, 
and  is  the  cause  of  various  nervous  troubles  such  as  chorea  or 
epilepsy  and  other  forms  of  spasms.  This  hooded  condition  may 
be  the  result  of  non-development,  but  is  usually  in  the  adult,  the 
result  of  adhesions  which  bind  the  glans  down.  The  labia 
majora  divide  at  their  anterior  or  superior  extremities,  the  part 
or  fold  above  the  clitoris  forming  its  prepuce,  and  the  part  below, 
its  frenulum.  Sometimes  these  parts  adhere,  thus  encapsulat- 
ing the  glans  clitoridis.  In  other  cases  the  lips  do  not  separate, 
hence  the  congenital  type  of  hooded  clitoris.  In  either  case  it 
is  a  source  of  irritation  and  is  the  cause  of  various  reflex  troubles. 
To  illustrate  this:  I  saw  a  case  in  which  there  was  spasmodic 
twitching  of  the  limbs  which  came  on  daily,  due  to  adhesions  of 
the  clitoris,  which  on  being  removed  gave  immediate  relief.  In 
cases  resulting  from  inflammation,  the  adhesions  can  be  broken 


DISEASES    OF   THE    VULVA.  153 

manually.  In  congenital  cases  a  slit  in  the  membrane  covering 
the  glans  has  to  be  made,  thereby  exposing  and  freeing  it. 

Diseases  of  the  meatus  are  comparatively  rare.  Urethral 
caruncles  are  occasionally  found.  They  are  vascular  tumors  or 
angiomata  of  the  urethra  at  or  near  the  meatus  urinarius.  The 
diagnosis  is  easily  made  by  inspection.  The  growth  consist  of 
a  bright  red  excresence,  in  shape  hke  a  strawberry  or  red  rasp- 
berry, springing  from  the  side  of  the  meatus.  They  vary  as  to 
size;  the  largest  seen  by  the  author  was  about  the  size  of  a  small 
marble. 

The  cause  is  not  well  understood,  injury  being  the  most 
common.  The  injury  is  to  the  urethra,  by  which  the  blood, 
vessels  are  directly  bruised  and  results  from  the  awkward  use  of 
instruments  or  from  a  fall  on  the  part. 

The  chief  and  almost  constarit  symptom  is,  painful  and 
frequent  micturition.  Intercourse  is  ver}^  painful  or  impossi- 
ble; locomotion  is  difficult  on  account  of  the  pain  in  the  parts 
whenever  jarred  or  moved.  At  or  near  the  menstrual  period  the 
enlargement  is  greatest  and  most  sensitive,  hence  the  above 
symptoms  are  exaggerated  at  this  time,  and  in  some  cases  the 
patient  can  seldom  find  an  easy  posture.  In  chronic  urethritis, 
the  mucous  membrane  may  become  everted,  thus  giving  rise  to 
symptoms  similar  to  those  from  a  caruncle. 

The  usual  treatment  is  removal,  either  by  a  caustic  or  the 
knife.  This  is  not  always  successful  as  a  cure,  since  it  may  re- 
turn. In  some  cases  it  can  be  absorbed,  in  others  the  tumor 
will  remain  but  loses  its  fiery  red  color,  after  which  the  sensi- 
tiveness diminishes. 

The  vulva  is  often  the  seat  of  injuries.  The  patient  may 
fall  astride  a  chair  or  other  object,  this  occurring  in  servants 
engaged  in  cleaning  windows;  or  in  bicyclists  who  are  thrown 


154  DISEASES    OF    WOMEN. 

forward  on  the  iron  frame  of  the  wheel.  Children  while  at  play 
may  fall  astride  a  picket  fence  or  be  injured  by  sliding  down  an 
incline.  In  such  cases  as  the  above,  the  blood  vessels  are  caught 
against  the  pubic  bone  and  often  severed,  the  escape  of  blood  in 
such  cases  forming  a  hematocele.  The  hemorrhage  is  very  copi- 
ous on  account  of  the  abundant  anastomosis  of  these  veins  and 
arteries. 

Parturition  sometimes  causes  an  injury  to  the  vulva,  especi- 
ally if  the  case  is  not  properly  cared  for.  Reed  says:  "Con- 
tusions of  the  labia  and  sometimes  of  the  vulvo-vaginal  glands 
are  due  in  the  majority  of  instances,  to  a  failure  of  the  head  to 
rotate  into  the  conjugate  diameter  of  the  outlet  of  the  pelvis. 
Not  infrequently  does  the  careless  use  of  forceps  cause  lacera- 
tion of  these  parts."  Complete  rotation  should  be  obtained  before 
extension  is  well  under  way.  This  is  secured  by  local  manipula- 
tion when  labor  pain  is  on. 

VAGINITIS.  Vaginitis  or  colpitis  is  an  inflammation  of  the 
mucous  membrane  of  the  vagina.  The  mucous  lining  of  the 
vagina  resembles  very  closely  in  structure  that  of  the  skin,  hav- 
ing few,  if  any,  submucous  glands.  The  vaginal  secretion  is 
acid,  and  is  germicidal  in  action,  during  health.  During  the 
menstrual  period,  the  puerperium  and  in  case  of  leucorrhea,  the 
discharge  is  faintly  acid  or  alkaline — a  condition  favorable  to 
the  growth  of  micro-organisms.  Stroganoff  claims  that  the 
vagina  of  the  new  born  is  free  from  micro-organisms  but  that 
"baths,  washings  and  especially  the  application  of  oleaginous 
substances  favor  the  entrance  of  germs."  Even  if  they  do  enter 
they  are  harmless  until  the  vitality  of  the  part  is  lowered  from 
other  causes.  Kronig  asserts  that  "all  secretions  alike  contain 
no  pathogenic  germs.  All  secretions  are  equally  germicidal, 
though  the  vitality  of  the    germs  differs.     It  takes  twice  the 


DISEASES    OF   THE    VULVA.  155 

time  to  kill  the  staphylococcus  that  it  does  to  destroy  the  strep- 
tococcus." 

According  to  the  investigations  of  many,  the  normal  vaginal 
secretion  is  of  a  whitish,  crumbling  material  of  the  consistency 
and  appearance  of  curded  milk,  containing  little  mucus  and 
giving  an  intensely  acid  reaction.  The  pathological  secretion,  on 
the  other  hand,  is  of  a  yellowish  or  greenish  yellow  color,  cream 
like  in  consistency  and  weakly  acid  or  neutral.  The  vagina 
infected  with  pyogenic  micro-organisms  will  become  aseptic 
in  from  a  few  hours  to  two  or  three  days.  Any  injection  or 
douche  which  dilutes  or  washes  away  the  normal  vaginal  secre- 
tion lessens  the  germicidal  action.  This  is  proven  by  the  in- 
vestigation of  various  writers.  In  a  series  of  experiments  Kronig 
found  that  a  solution  of  corrosive  sublimate  for  irrigation  de- 
stroys the  germicidal  action,  probably  by  precipitation  of  the 
albumen,  while  plain  water  but  lessens  it. 

Experiments  have  been  made  by  taking  three  normal  sub- 
jects and  introducing  pathogenic  micro-organisms  into  the 
vagina.  In  one  case  no  injections  were  used  immediately  be- 
fore the  introduction  of  the  germs,  and  the  vagina  rid  itself  of 
the  micro-organisms  within  a  few  hours.  In  the  second,  a  thor- 
ough preparatory  plain  water  vaginal  douche  was  given;  as 
a  result  it  took  several  days  for  the  vagina  to  rid  itself  of  the 
bacteria.  In  the  third  case  an  antiseptic  douche  was  given 
just  before  the  germs  were  introduced  into  the  vagina  with  the 
result  that  it  did  not  entirely  free  itself  of  them  before  the  fourth 
day.  From  this  it  is  necessary  to  infer  that  injections  of  cor- 
rosive sublimate  or  water  are  prejudicial.  Menje,  in  his  investi- 
gations on  the  nonpuerperal  women,  introduced  pyogenic  organ- 
isms into  the  vagina  in  eight  patients  and  found  that  the  vagina 
cleansed  itself  from  these  organisms  in  periods  varying  from  two 


166  DISEASES   OF   WOMEN. 

and  one-half  hours  to  three  days.  I  quote  these  statements  be- 
cause they  illustrate  the  osteopathic  theory  that  a  healthy  mucous 
MEMBRANE  is  SELF-CLEANSING,  its  SECRETIONS  germicidal,  and 
that  WASHES  IMPAIR  ITS  VITALITY.  I  have  had  a  number  of 
cases  which  conclusively  proved  to  me  that  the  above  statements 
are  true. 

The  liquor  amnii  is  another  antiseptic  fluid  designed  by 
nature  to  protect  the  internal  organs.  After  delivery  of  a  child 
in  which  the  fingers  were  covered  with  this  fluid,  I  have  noticed 
that  they  were  wrinkled  and  the  skin  drawn  up.  This  is  not  due 
entirely  to  the  amniotic  fluid  but  to  the  vaginal  secretions.  I 
mention  this  to  prove  how  complete  the  body  is  in  resources  to 
protect  itself,  and  to  show  that  disease,  especially  vaginitis,  usual- 
ly comes  from  external  causes,  and  that  pyogenic  bacteria  are 
introduced  by  instruments  or  douches.  Another  idea  has  re- 
cently been  advanced  relative  to  the  germicidal  action  of  the 
vagina.  GilHam  (p.  110)  says:  "The  vagina  and  those  portions 
of  the  genital  tract  above  the  vagina  are  still  further  safeguarded 
by  a  germ  which  inhabits  the  canal,  which  is  not  pathogenic  and 
which  produces  an  acid  secretion  which  is  inimical  to  other  germs. 
This  is  known  as  the  acid  secreting  germ  of  Doderlien."  This 
germ,  if  acting  normally,  prevents  the  existence,  or  at  least  the 
multiplication,  of  pathogenic  germs  in  the  genital  tract.  The 
gonococcus  of  Neiser  is  perhaps  an  exception,  yet  the  writer  believes 
it  to  be  harmless  when  deposited  on  a  healthy  mucous  mem- 
brane. The  above  facts  alone  would  negate  vaginal  douches, 
since  such  wash  away  those  helpful  germs,  thus  weakening  the 
natural  defense's. 

The  VARIETIES  of  vaginitis  depend  on  degree  of  inflamma- 
tion, usually  it  is  divided  into  the  simple  and  the  specific. 
This  classification  into  the  simple  and  specific  vaginitis  depends 


DISEASES    OF   THE    VULVA.  157 

upon  whether  the  toxic  elements  arise  from  within  or  are  intro- 
duced from  without.  Simple  vaginitis  depends  upon  some  toxic 
element  which  has  been  produced  by  the  changes  which  have 
taken  place  in  the  stagnated  blood.  Blood,  in  order  to  be  pure, 
must  be  moving,  and  if  the  rapidity  is  lessened  \atality  is  lowered, 
and  if  the  flow  is  entirely  stopped,  fermentation  and  putrefaction 
follow.  In  the  specific  form  the  toxic  element  is  introduced  from 
without,  the  gonorrheal  form  being  the  most  common  type. 

THE  CAUSES  of  simple  vaginitis  are  injuries  to  the  walls 
by  means  of  some  instrument,  as  in  an  attempted  abortion,  ex- 
cessive or  awkward  coitus,  irritating  discharges,  injections  too 
cold  or  containing  injurious  chemical  agents,  caustics,  decompos- 
ing compounds,  and  tampons  or  pessaries  that  have  been  left  in 
in  the  vagina  for  some  time.  Herman  says  that  puerperal  vagi- 
nitis, that  is  the  form  due  to  injurj^  of  the  vaginal  walls  at  labor, 
is  the  most  common  type.  The  vagina  is  often  bruised,  scraped 
or  even  lacerated  in  some  instances,  and  quite  often  too,  in  prim- 
ipara,  if  care  and  caution  are  not  used. 

Any  lesion  affecting  the  vaso-motor  center  will  cause  con- 
gestion, and  unless  corrected,  will  terminate  in  inflammation. 
The  most  common  lesion  is  at  the  lumbo-sacral  articulation  or  at 
the  sacro-iliac  synchondrosis.  I  saw  a  case  recently  in  which 
the  lesion  was  at  the  fourth  and  fifth  lumbar,  but  usually  in  those 
cases  an  endometritis  complicates  the  vaginitis.  In  many  of  these 
cases  the  lesions  are  higher,  that  is  in  the  upper  lumbar  region, 
and  primarily  affect  the  uterus,  which  in  turn  produces  vaginitis 
on  account  of  the  irritating  discharges.  In  inflammation  of  the 
cervix  uteri,  the  disease  may  travel  by  continuity  of  tissue  to  the 
vaginal  walls  and  there  set  up  a  secondary  inflammation. 

Displacements,  congestion  and  inflammation  of  the 
uterus  produce  vaginitis  by   interfering  with  the  venous  return 


158  DISEASES   OF    WOMEN. 

from  the  vagina.  Some  of  the  worst  cases  the  writer  has 
ever  treated  followed  uterine  inflammation  which  resulted  from 
a  hard  labor  in  which  the  cervix  was  lacerated.  As  mentioned 
above,  the  intensely  acrid  discharge  erodes  the  surface  of  any 
part  with  which  it  comes  in  contact.  The  writer  has  seen 
cases  in  which  the  discharge  was  so  strong  that  the  integument  of 
the  INNER  SIDES  OF  THE  THIGHS  was  ERODED  at  the  poiuts  at 
which  some  of  the  discharge  accidentally  came  in  contact.  In 
other  cases  a  deposit  of  thick,  creamy,  leucorrheal  discharge  part- 
ly or  completely  filling  thefomices,  sets  up  an  irritation  sufficient- 
to  excite  inflammation.  Subinvolution  of  the  vaginal  walls 
following  childbirth  is  often  the  cause  of  a  chronic  form  of  vagi- 
nitis, since  the  vaginal  walls  as  well  as  the  uterus  involute  after 
delivery,  and  in  subinvolution  of  one,  the  other  is  affected. 

The  SPECIFIC  form  is  caused  by  gonorrheal  infection.  It 
is  hard  to  cure  on  account  of  its  tendency  to  spread  to  the  uterus 
and  Fallopian  tubes  and  there  set  up  a  chronic  inflammation. 

The  important  pathological  point  is  congestion.  The  blood 
vessels  are  engorged,  the  surface  red  and  painful,  and  in  the  worst 
cases  permanent  degenerative  changes  take  place,  such  as  a 
deposit  of  scar  tissue  in  the  walls  of  the  vagina. 

The  CLINICAL  symptoms  of  vaginitis  do  not  differ  very  much 
in  the  various  types  of  inflammation  except  that  in  the  specific 
type  they  are  more  intense.  There  is  heat,  sense  of  dryness  at 
first,  and  burning  of  the  vagina.  This  extends  to  the  urethra, 
causing  frequent,  imperfect  and  burning  micturit'on.  At 
first  there  is  little  or  no  secretion,  but  in  a  few  days  there  is  a 
leucorrheal  discharge  of  an  offensive  odor.  Pains  of  a  throbbing 
character  are  referred  to  the  pelvis  and  groins.  There  is  red- 
ness and  excoriation  of  the  vaginal  opening.  The  labia  are 
swollen,  red  and  irritable;  vaginal  examination    causes   great 


DISEASES    OF    THE    VULVA.  159 

pain  and  often  cannot  be  tolerated.  The  inguinal  lymphatic 
GLANDS  are  frequently  tender  and  enlarged,  their  function 
being  to  collect  the  toxic  elements  resulting  from  the  inflamma- 
tion and  prevent  them  from  being  throwTi  into  the  general  cir- 
culation. In  acute  cases  the  usual  malaise,  anorexia  and  fever 
are  found. 

The  above  symptoms  vary  with  the  degree  of  inflammation; 
they  being  lessened,  or  some  of  them  absent  in  the  simple  form, 
while  in  the  aggravated  form  they  are  exaggerated. 

The  symptoms  of  the  specific  form  of  vaginitis,  are  similar 
to  those  of  the  simple  form,  but  are  more  intense.  The 
disease  is  not  confined  to  the  vaginal  walls  but  extends  to 
the  urethra.  In  fact,  the  meatus  seems  to  be  the  seat  of  the  dis- 
ease in  that  the  inflammation  is  greatest  at  that  point.  Traces 
of  the  disease  remain  for  quite  a  while,  after  an  apparent  cure. 
The  parts  are  in  the  beginning  very  tense,  red,  hot  and  dry,  but 
after  a  few  days  a  muco-purulent  discharge  appears.  Its  diag- 
nosis depends  upon  the  discovery  of  the  presence  of  the  gonococ- 
cus  of  Neiser,  which  is  ascertained  by  microscopical  examina- 
tion. 

In  making  a  microscopic  preparation,  obtain  the  secretion, 
spread  in  a  thin  film  on  a  clean  glass  slide ;  allow  to  dry  in  the  air 
then  pass  it  through  the  flame  of  an  alcohol  lamp  two  or  three 
times,  being  careful  to  have  the  pus  side  turned  up.  A  drop  or 
two  of  dilute  water  solution  of  one  of  the  analine  dyes,  methyl 
blue  being  commonly  used,  is  then  applied  by  a  glass  rod,  and  left 
on  for  two  or  three  minutes.  The  specimen  should  then  be  care- 
fully dried,  mounted  in  Canada  balsam  and  studied  with  a  high 
power  oil  immerison  lens.  The  gonococcus  may  be  recognize i 
by  the  following  description :  They  occur  in  pairs  or  in  groups  of 
four,    but   generally   in    the    form   of   diplococc'.     According   to 


160  DISEASES    OF    WOMEN. 

Sternberg,  the  flattened  surfaces  face  each  other  and  are  only 
separated  in  stained  preparations  by  a  small  unstained  interspace. 
They  have  aptly  been  compared  in  shape  to  "biscuits"  with 
the  FLAT  SURFACES  IN  APPOSITION.  In  chronic  cases,  the  micro- 
organisms are  embedded  in  the  epithelial  cells.  When  a  pa- 
tient comes  to  you  suffering  with  some  form  of  vaginitis,  be 
careful  as  to  the  diagnosis  you  make  and  do  not  mistake  a  sim- 
ple VAGINITIS  for  a  specific,  since  the  patient's  social  happiness 
may  depend  upon  your  diagnosis. 

The  adhesive  type  of  vaginitis  is  found  in  cases  of,  or  rather 
follows,  marked  inflammation  in  old  women  and  sometimes  in 
young  girls.  The  fornices  grow  fast  to  the  cervix;  sometimes 
they  are  entirely  obliterated  and  the  vaginal  lumen  partly  or 
completely  obstructed. 

The  prognosis  in  the  simple  form  of  vaginitis  is  good.  In 
the  specific  type  there  is  grave  danger  of  the  disease  reaching 
the  uterus,  tubes  and  ovaries.  In  such  cases  a  cure  is  the  excep- 
tion, especially  in  cases  of  a  year  or  more  duration.  Since  the 
prognosis  depends  on  limiting  the  diseased  area,  care  should  be 
taken  in  the  giving  of  injections  as  the  micro-organisms  may  be 
carried  higher,  even  into  the  uterus. 

Treatment  consists  in  first  removing  the  noxious  elements 
or  toxic  material,  and  second,  restoring  normal  circulation.  If 
there  is  any  irritating  discharge  treat  the  source  of  that  discharge. 
If  a  lesion  is  found,  whether  bony  as  in  the  lumbar  region,  or  a 
displaced  uterus,  correct  the  disturbance.  In  short,  treat  any 
ABNORMALITY  which  may  affect  the  vaso-motor  supply  of  the 
vagina  or  interfere  with  the  venous  return.  Since  the  veins 
DRAINING  the  VAGINA  DRAIN  THE  UTERUS,  it  follows  that  Uterine 
disease,  especially  displacement,  will  cause  congestion  of  the 
vagina,  thus  predisposing  it  to  inflammation  and  other  diseases. 


DISEASES    OF   THE    VULVA,  161 

Washes  and  douches  are  usually  prescribed  but  should  be  used 
only  for  cleanliness  sake,  or  as  a  palliative  treatment.  Lecal 
treatment  over  the  sacrum  and  stimulation  over  the  lower  lum- 
bar region  will  help,  also  treatment  over  the  abdomen  to  remove 
the  pressure  exerted  by  the  intestines. 

If  the  inflammation  is  of  specific  origin,  use  as  a  wash  a  warm 
rose  colored  solution  of  permanganate  of  potassium,  three  times 
daily,  until  the  microbes  are  destroyed,  which  is  indicated  by 
cessation  of  the  discharge  of  pus,  this  usually  taking  about  a 
week.  The  dry  treatment  is  recommended  in  cases  of  specific 
vaginitis,  in  which  it  can  be  substituted.  The  vaginal  walls  are 
exposed  by  means  of  a  Sims  speculum,  and  then  thoroughly 
cleansed  and  wiped  dry  by  a  cotton  swab  saturated  with  some 
antiseptic  solution,  such  as  bicloride  of  mercury  or  bismuth.  As 
a  rule  it  is  not  policy  for  the  osteopath  to  treat  venereal  diseases ; 
he  should  rather  refer  such  cases  to  the  specialist. 

VAGINISMUS.  This  affection  consists  of  a  peculiar  hyper- 
esthesia of  the  nerves  of  the  mucous,  membrane  of  the  vagina,, 
irritation  of  which  produces  a  painful,  spasmodic  contraction  of 
the  muscles  surrounding  the  vagina  or  pelvic  floor,  resulting  in 
tightly  closing  the  lumen  of  the  vagina,  preveistting  or  making 
DIFFICULT  digital  or  instrumental  examination,  or  coition. 
It  is  quite  a  rare  disease,  found  principally  in  young,  nervous, 
hysterical  women  who  suffer  from  dysmenorrhea  from  flexion 
of  the  uterus.  It  is  not  really  a  disease  of  the  vagina  with  path- 
ological changes  as  it  is  ordinarily  understood,  but  only  a  nerv- 
ous condition  dependent  on  an  irritation  to  the  muscles  of  the 
pelvic  floor  or  to  a  general  nervous  irritability. 

It  is  usually  produced  by  some  local  irritation,   such  as 

a  urethral    caruncle    or    a  diseased  hymen,    which,  when 

touched,  causes  pain  and  contraction.  Sometimes  the  remains 
11 


162  DISEASES    OF    WOMEN. 

of  the  hymen  continue  to  be  irritable  for  some  time  after  it 
has  been  ruptured,  they  not  having  properly  healed,  this  giving 
rise  to  great  pain  during  intercourse  or  an  attempt  to  make  a 
vaginal  examination. 

A  DISPLACED  COCCYX  is  quite  often  the  cause  of  vaginismus. 
If  the  coccyx  is  displaced  laterally  or  backward  it  puts  on  a  ten- 
sion the  muscles  attached  to  it;  if  thrown  forward  it  produces 
pressure  on  the  posterior  vaginal  wall.  If  tenderness  is  pres- 
ent at  the  sacro-coccygeal  articulation,  or  at  the  tip  of  the  bone, 
the  lesion  is  in  all  probability  the  cause  of  the  disease.  Pelvic 
INFLAMMATION  due  to  metritis  or  uterine  displacement  affects 
the  sacral  nerves  by  extension  of  the  inflammatory  process  to 
them;  this  in  turn  affects  the  muscles  innervated  by  them,  viz., 
the  muscles  of  the  pelvic  floor.  A  tender  ovary  is  often  fovmd 
in  cases  of  vaginismus  which  when  touched,  causes  contraction 
of  the  muscles  of  the  pelvic  floor. 

If  the  patient's  general  nervous  system  is  impaired  the  nerv- 
ous form  of  vaginismus  will  be  produced,  there  being  no  local 
disturbances.  The  hyperesthesia  is  general,  as  is  manifested  by 
the  nervousness  and  general  tenderness.  In  such  cases  spinal  irrita- 
tion is  marked  and  the  vertebrae  separated  on  account  of  the 
relaxation  of  the  ligaments,  thus  producing  hypermobility. 
Vaginitis  is  a  cause  of  this  condition,  since  it  produces  contraction 
of  the  sphincter  muscle  with  great  pain,  when  the  tender  vagi- 
nal walls  are  irritated.  Lesions  found  in  the  lower  lumbar  re- 
gion, affect  the  innervation  to  the  vagina  and  if  the  lesion  irri- 
tates instead  of  inhibits  the  nerves,  sacral  and  pudic,  vaginismus 
will  result. 

The  symptoms  are  those  of  dyspareunia  and  spasmodic 
contractions  of  the  vaginal  walls  whenever  an  attempt  is  made 
to  give  a  local  examination.     As  soon  as  the  finger  comes  in  con- 


DISEASES    OF    THE    VULVA.  163 

tact  with  the  site  of  the  hymen, the  patient  will  complain  of  agon- 
izing pain  and  become  very  much  disturbed  in  her  nervous  sys- 
tem. Should  the  examination  be  persisted  in,  the  introduction 
of  the  finger  will  be  found  almost  impossible,  and  if  forced  into 
the  canal  is  tightly  grasped  by  the  sphincter  muscle. 

This  affection,  when  chronic,  gives  rise  to  general  nervous- 
ness, irritability  and  spinal  irritation,  thus  becoming  a  real, 
distressing  form  of  disease  in  addition  to  its  local  effects. 

The  PALLIATIVE  treatment  consists  of  strong  inhibition  of 
the  nerves  supplying  the  vagina.  This  is  best  accomplished  by 
pressure  applied  to  the  posterior  sacral  region.  This  relaxes 
and  relieves  but  only  for  a  short  time.  The  cause  must  be  re- 
moved; that  is,  the  lumbar  and  sacral  lesions  corrected.  Often 
the  inhibitive  treatment  is  given  before  attempting  a  local  va- 
ginal examination  or  treatment,  and  is  usually  helpful  and  ad- 
visable. 

Rectal  tenesmus  is  a  similar  trouble  and  can  be  relieved 
by  a  similar  treatment.  Vesical  tenesmus  can  also  be  relieved  by 
inhibition  of  the  nerves  innervating  the  part. 

Sometimes  vaginismus  is  treated  by  dilatation  of  the  va- 
gina either  by  a  glass  dilator  or  by  means  of  the  finger.  By 
doing  this  the  contraction  is  forcibly  overcome;  this  being  a  good 
form  of  treatment  only  in  a  few  cases.  When  instruments  are 
used  for  the  purpose  of  dilatation  of  the  vagina,  the  patient 
should  be  anesthetized.  Parturition  is  a  cure  for  this  condi- 
tion; the  only  trouble  is  that  pregnancy  is  usually  precluded  by 
the  disease. 

Surgeons  have  devised  operations  for  the  cure  of  vaginismus. 
The  most  important  is  Sims',  by  which  the  bulbo-cavernosi 
muscles  are  severed.  In  cases  of  disease  of  the  hymen  in  which 
some  of  the  canmculae  myrtiformes  are  enlarged  and    tender, 


164  DISEASES     OF    WOMEN. 

removal  of  these  sensitive  lumps  is  indicated,  if  the  case  does  not 
yield  to  the  ordinary  osteopathic  treatment  for  same.  By  the 
osteopathic  method,  the  constrictor  muscles  are  relaxed  by  in- 
hibiting the  nerves  supplying  them  and  physiological  dilatation 
results. 

A  case  was  reported  to  me  by  Dr.  Anna  Hannah  which  de- 
serves special  notice.  The  patient  was  a  married  woman  and 
during  the  eight  years  of  married  life,  intercourse  was  impossible 
on  account  of  the  spasms  or  contractions  of  the  vagina,  they  be- 
ing so  severe  that  the  act  was  prohibited.  Various  treatments 
had  been  resorted  to,  such  as  forcible  dilatation  under  anesthesia, 
the  use  and  wearing  of  dilators,  etc.,  but  the  patient  did  not  im- 
prove. Under  anesthesia  a  digital  vaginal  examination  could 
easily  be  made  showing  no  organic  disturbance.  Under  osteo- 
pathic treatment  the  case  was  entirely  cured,  the  patient  be- 
coming pregnant  and  giving  birth  to  a  living  child.  The  cure 
was  accomplished  by  correcting  some  lesions  found  in  the  lower 
lumbar  region,  coupled  with  strong  inhibition  over  the  sacrum 
and  frequent  attempts  at  giving  local  vaginal  treatment.  At 
first  these  local  treatments  were  decidedly  incomplete  in  that  only 
a  partial  intromission  was  possible  and  that  very  painful.  After 
a  few  weeks  the  treatments  were  lesfg  painful ;  the  patient  became 
less  nervous,  her  confidence  having  been  won,  and  gradually  the 
irritability  disappeared. 

CYSTOCELE.  Cystocele  or  vesico-vaginal  hernia,  consists 
of  a  descent  of  the  bladder  so  as  to  impinge  upon  the  vaginal 
canal  and  forcing  the  anterior  wall  downward  into  the  lumen  of 
the  vagina.  It  is  really  a  prolapsus  of  the  anterior  vaginal  wall 
which  is  the  principal  support  of  the  bladder.  Either  of  the 
vaginal  walls  may  prolapse  forming  a  bulging,  softened  tumor  of 
the  part,  such  as  rectocele,  enterocele  or  cystocele,  the  last  being 
the   most   common. 


DISEASES    OF   THE    VULVA.  165 

Since  the  disease  is  seldom  seen  in  nullipara,  childbirth  is, 
almost  invariably,  the  cause  of  this  condition,  the  vaginal  canal 
being  so  enormously  distended  in  some  cases  that  the  tone  of  the 
walls,  in  this  case  the  anterior  wall,  is  lost  and  the  bladder  pushes 
it  outward  and  downward.  If  the  wall  is  also  bruised  in  delivery, 
it  will  be  the  more  weakened  and  a  heavy  distended  bladder  may 
cause  a  prolapsus  of  it.  The  bladder  should  be  emptied  soon 
after  parturition  on  account  of  its  increased  weight  and  the 
weakness  of  its  support. 

Laceration  of  the  perineum  weakens  the  vaginal  walls, 
hence  may  be  the  cause  of  either  cystocele  or  rectocele.  Strain- 
ing at  stool  forces  the  pelvic  contents  downward,  and  if  the 
the  support  is  weakened  there  is  a  tendency  to  prolapsus  of  the 
different  organs.  To  prevent  this  during  the  peurperium  always 
insist  on  the  patient  using  a  bed  pan  for  at  least  two,  better 
three  weeks,  after  confinement.  Subinvolution  of  the  vagina 
is  a  cause,  since  by  it  the  vaginal  walls  are  weakened  and  if  the 
bladder  becomes  distended,  cystocele  will  follow.  The  osteo- 
pathic lesions  associated  with  this  trouble  are  located  in  the 
sacral  and  lumbar  regions  since  the  nerves  supplying  the 
vaginal  walls  originate  there.  Any  lesion  which  shuts  off 
a  part  of  the  nerve  force  weakens  the  muscle  which  is  supplied 
by  that  nerve.  Since  cystocele  is  the  result  of  the  weakening 
of  the  anterior  vaginal  wall  we  must  go  to  its  innervation  for  the 
cause;  it  being  found  in  the  muscular  or  bony  lesions  which  in- 
hibit  the   nerve   force. 

Frequent  and  imperfect  micturition  are  the  principal 
symptoms  of  this  trouble.  The  bladder  being  forced  downward 
produces  an  abnormal  curve  of  the  urethra  which  prevents  the 
bladder  from  entirely  emptying  itself.  The  retained  urine  de- 
composes and  sets  up    a  cystitis.     There  is  pain,  a  burning  or 


166 


DISEASES    OF    WOMEN. 


scalding  sensation,  and  vesical  tenesmus  whenever  an  attempt  is 
made  to  evacuate  the  bladder.  The  patient  describes  a  lump  or 
protrusion  in  the  anterior  vaginal  wall  which  is  present  when  she 
stands,   but  disappears   when  in   the  recumbent    posture.      By 


Fk;.  57. — Cystocele.     (From  photo  of  author's  case.) 

separating  the  greater  lips  this  tumor  can  be  seen  on  the  anterior 
vaginal  wall.  It  is  covered  by  rugus  vaginal  mucous  membrane 
and  decreases  in  size  or  even  completely  disappears  by  evacuating 
the  bladder  by  means  of  a  catheter. 


DISEASES    OF   THE    VULVA.  167 

111  mild  types  the  tumor  will  disappear  on  digital  pressure 
on  the  part,  especially  if  the  patient  is  in  the  genu-pectoral  posi- 
tion when  treatment  is  given.  The  best  position  in  which  to  ex- 
amine a  patient  with  either  cystocele  or  rectocele  is  the  squatting 
posture,  since  in  this  position  the  prolapsus  of  the  vaginal  wall  is 
at  its  worst.  The  examination  can  be  readily  and  best  made 
by  means  of  a  hand  mirror,  so  held  that  the  physician  standing 
behind  the  patient  and  looking  over  her  shoulder,  can  see  the 
vulva  with  the  tumor  reflected  in  the  glass.  There  is  a  dragging 
sensation  or  feeling  of  weight,  this  being  more  marked  if  the 
bladder  is  not  emptied  frequently.  Prolapsus  of  the  entire  vagina 
and  occasionally  of  the  uterus,  accompany  this  condition,  in  fact 
there  is  some  prolapsus  of  the  uterus  in  every  case  of  cystocele. 
The  ligaments  supporting  the  uterus  are  weak  and  relaxed,  thus 
allowing  very  free,  even  too  free,  movement  of  the  uterus.  The 
writer  has  treated  cases  that  had  been  diagnosed  as  cystocele,  but 
on  close  examination  they  proved  to  be  cases  of  prolapsus  of  the 
uterus  with  some  eversion  of  the  vaginal  walls,  but  not  sufficient 
to  pull  the  bladder  down.  The  cervix  was  forced  down  upon  the 
anterior  vaginal  wall  almost  to  the  external  orifice,  producing  a 
tumor,  a  sense  of  weight  and  interference  with  micturition. 

The  treatment  consists  in  relieving  the  pressure  on  the  an- 
terior vaginal  wall  and  restoring  the  tonicity  to  the  supports  of 
the  bladder.  The  pressure  can  be  relieved  by  frequent  evacua- 
tion of  the  bladder,  if  necessary,  by  the  use  of  the  catheter.  Some- 
times the  folds  in  the  vaginal  wall  must  be  straightened  out  in 
order  to  remedy  the  curve  existing  in  the  urethra.  This  can  best 
be  done,  and  in  some  eases  only  accomplished,  by  introducing  a 
sound  into  the  urethra  and  lifting  the  bladder  and  anterior  va- 
ginal   wall. 


168  DISEASES  OF    WOMEN. 

The  SUPPORTS  of  the  bladder  can  be  strengthened  by  correct- 
ing the  lesions  which  interfere  with  their  innervation,  and  strong 
stimulation  over  the  sacrum,  to  increase  their  tonicity.  Local 
digital  treatment  is  indicated  in  some  cases  in  order  to  push  the 
bladder  up  and  correct  the  prolapsed  condition  of  the  vagina. 
This  treatment  consists  principally  in  a  circular  motion  of  the 
finger;  in  other  words,  a  rimming  out  of  the  vagina. 

Astringent  douches  have  been  advocated;  they  will  prob- 
ably relieve  temporarily  in  some  cases  but  will  not  cure  and  even 
make  the  condition  worse  if  long  continued.  Sometimes  an  oper- 
ation is  resorted  to  by  which  a  portion  of  the  wall  is  resected; 
that  is,  by  a  transverse  denudation,  and  the  edges  brought  to- 
gether. When  union  takes  place,  the  lumen  of  the  vagina  is 
lessened  in  proportion  to  the  amount  of  tissue  removed.  This 
operation   is    called   colporraphy. 

RECTOCELE.  A  reetocele  is  a  tumor  produced  by  the  rec- 
tum forcing  outward  and  forward  the  posterior  vaginal  wall. 
Sometimes  other  structures  will  force  it  forward,  yet  the  tumor  is 
still  called  a  reetocele;  but  technically,  a  reetocele  is  a  tumor 
produced  by  the  rectum. 

The  causes  are  similar  to  those  producing  cystocele,  except 
that  constipation  takes  the  place  of  a  distended  bladder.  Lacer- 
ation of  the  perineum  or  posterior  vaginal  wall  is  a  very  com- 
mon cause.  This  weakens  the  support  of  the  rectum  so  that 
when  distended  the  vaginal  wall  is  forced  forward.  If  the  pa- 
tient is  not  constipated  the  rectum  is  empty  only  for  a  short  per- 
iod just  preceding  defecation,  but  if  constipation  is  present,  the 
rectum  is  habitually  distended,  hence  the  constant  pressure 
against  the  weakened  posterior  vaginal  wall,  produces  a  reetocele. 
As  mentioned  above,  any  lesion  which  affects  the  tonicity  of  the 
vaginal  walls  will  produce  either  reetocele  or  cystocele  if  pressure 


DISEASES    OF   THE    VULVA. 


169 


is  exerted  upon  them.  Lesions,  by  impairing  the  nerve  force  to 
the  pelvic  floor,  cause  the  perineal  body  to  sink  downward  and 
backward,  which  thing  alone  is  sufficient  to  cause  rectoeele. 

Among  the  symptoms  are  found  constipation,  hemorrhoids, 
tenesmus,    rectal    irritation    and    sometimes    inflammation.     On 


Fig.  58. — Rectoeele.    (From  photo  of  author's  CJise.) 

vaginal  examination  the  tumor  on  the  posterior  wall  can  be 
found  bulging  into  the  vaginal  canal.  On  rectal  examination  a 
fossa  or  depression  will  be  discovered,  corresponding  to  the  cav- 
ity of  the  tumor.  This  is  especially  noticed  in  the  aged.  In 
such  cases,  or  in  chronic  or  pronounced  cases,  the  cavity  some- 
times measures  two  or  more  inches  in  width.  The  feces  collect 
there  and  the  rectal  wall  is  depressed,  giving  rise  to  chronic  con- 


170  DISEASES    OP    WOMEN. 

stipation,  which  is  an  effect  or  result  of  rectocele  rather  than  a 
cause. 

The  treatment  is  similar  to  that  of  cystocele ;  that  is,  endeavor 
to  restore  tonicity  to  the  vaginal  walls.  Relieve  the  constipa- 
tion if  possible,  that  being  a  very  important  part  of  the  treat- 
ment. In  case  the  perineal  body  is  torn  it  should  be  repaired, 
since  the  walls  will  be  weak  as  long  as  that  injury  exists.  Local 
rectal  treatments  are  advisable  to  remove  the  folds  of  the  mucous 
membrane  of  the  rectum.  It  gets  rolled  down  upon  itself  and 
mechanically  obstructs  the  lumen  by  pulling  down  the  sphincter 
muscles  with  it.  Local  vaginal  treatment  given  to  straighten 
the  folds  of  the  vaginal  wall  and  to  lift  the  uterus  is  to  be  recom- 
mended occasionally.  In  cases  in  which  a  laceration  of  the 
posterior  vaginal  wall  is  the  cause,  a  surgical  operation  is  ad- 
visable. 

OTHER  AFFECTIONS  OF  THE  VAGINA.  The  vagina  is 
the  seat  of  various  other  affections,  such  as  innocent  and  malig- 
nant growths,  papillae,  injuries  and  abnormal  discharges.  In 
cases  in  which  there  is  a  twisted  pelvis,  displaced  ilium  or  sacrum, 
the  blood  may  become  stagnated  in  the  vaginal  walls.  This 
venous  congestion  gives  rise  to  an  abnormal  discharge  which  is 
called  vaginal  leucorrhea.  The  walls  are  smooth  and  covered 
with  a  slimy  fluid.  Rugae  are  absent  and  the  canal  can  be  di- 
lated to  a  very  great  extent.  The  tonicity  being  lost,  the  walls 
tend  to  prolapse,  and  with  them  prolapsus  of  the  uterus,  since 
they  form  one  of  the  principal  supports  of  the  uterus.  Along 
the  vaginal  walls  are  found  transverse  folds  or  wrinkles  which 
have  been  formed  by  the  relaxed  walls  rolling  upon  themselves 
These  not  only  show  that  the  walls  are  weakened,  but  that  they 
are  diseased  and  malnourished. 

Dryness  of  the  vaginal  walls  indicates  that  douches,  astring- 


DISEASES    OF   THE    VULVA.  171 

ent  or  otherwise,  have  been  used;  or  that  there  is  a  loss,  partial 
or  complete,  of  the  sexual  desire  or  activity,  or  both. 

The  use  of  alum  or  other  astringent  douches  are  advised  by 
some  physicians  in  cases  of  prolapsus  of  the  vaginal  walls,  loss  of 
tone,  etc.  Usually,  if  the  practice  is  indulged  in  for  a  very  long 
time,  that  is  over  a  month,  the  mucous  secreting  glands  are  de- 
stroyed or  impaired.  Moist  vaginal  walls,  in  cases  in  which  the 
secretion  is  normal  in  character,  are  normal  and  indicate  sexual 
activity  and  strength. 

Garrulity  of  the  vagina  or  vulva  or  flatus  vaginalis  are 
terms  applied  to  the  condition  in  which  air,  having  entered  the 
vagina,  is  expelled  with  a  noise.  This  occurs  with  movements 
of  the  body,  especially  walking  or  straining,  and  is  due  to  a  large, 
relaxed  vaginal  canal  with  a  patulous  ostium  vaginae  resulting 
from  subinvolution,  caused  especially  by  perineal  laceration. 
In  the  cases  treated  by  the  author,  there  was  a  history  of  douches 
having  been  used  in  all,  which  thing  constituted  the  most  im- 
portant of  all  causes.  Subinvolution  is  also  an  important 
cause.  In  some  of  these  cases  there  was  a  cavity  around  the 
cervix;  that  is,  the  fomices  were  so  distended  that  a  space  vary- 
ing from  one  to  three  inches  in  diameter,  was  discovered.  Pro- 
lapsus uteri  invariably  complicates  such  conditions.  The  treat- 
ment consists  in  restoring  tone  to  the  vaginal  walls,  thereby  se- 
securing  coaptation  of  the  walls.  This  is  accomplished  by  ad- 
vising the  patient  to  cease  using  the  douche  and  by  correcting 
lesions  which  interfere  with  the  normal  action  of  the  levator  ani 
muscles. 

Cysts  of  the  vagina  are  occasionally  met  with.  The  writer 
has  seen  several  cases  in  which  they  were  as  large  as  hen's  eggs. 
They  are  quite  superficial,  thin  walled  and  filled  with  a  clear 
serous  fluid.     Surgical  interference  by  which  the  cyst  is  removed 


172  DISEASES   OF   WOMEN. 

is  the  treatment  resorted  to  in  most  cases.  Some,  in  which  the 
cysts  were  small,  have  yielded  to  osteopathic  treatment. 

Atresia  of  the  vagina,  either  congenital  or  acquired,  is  some- 
times encountered.  The  writer  recently  examined  a  case  of  con- 
genital atresia  with  non-development  of  the  uterus,  and  under- 
development of  the  ovaries.  On  inspection  the  hymen  was  found 
to  be  perforate  but  by  widely  separating  the  labia  no  vaginal 
opening  or  canal  could  be  seen.  On  digital  examination  the 
finger  could  be  passed  as  far  as  the  first  joint.  On  rectal  exami- 
nation no  uterus  could  be  outlined.  On  questioning  the  pa- 
tient it  was  ascertained  that  she  had  monthly  symptoms  of  mens- 
truation which  had  recurred  regularly  for  several  years.  The 
patient  was  twenty  years  of  age.  The  conclusion  was  that  it 
was  a  case  of  congenital  absence  of  the  vagina  and  possibly  of  the 
uterus;  or  since  mohminawere  present,  it  was  a  case  of  developed 
ovaries  with  small  uterus.  In  such  cases  ovariotomy  is  the  only 
cure. 

Another  case  examined  by  Dr.  C.  E.  Still  and  myself,  re- 
vealed a  partly  developed  vagina  and  uterus.  After  inhibition 
of  the  clitoris  and  repeated  attempts  at  vaginal  examination  the 
uterus  was  finally  reached.  Repeated  examinations  dilated  the 
vagina  to  such  a  degree  that  menses  became  normal.  The  pa- 
tient, aged  nineteen,  had  never  menstruated  and  had  few  patho- 
logical symptoms  except  the  monthly  pain. 

Coccydinia  is  a  term  used  to  designate  a  pain,  often  intense 
and  constant,  located  at  the  coccyx,  from  which  point  it  radiates 
to  the  neighboring  parts.  Since  the  disease  is  almost  entirely 
confined  to  women  it  was  supposed  to  be  the  result  of  some  dis- 
ease of  the  female  genitalia.  However,  it  most  frequently  occurs 
as  a  result  of  some  injury  to  or  disease  of  the  coccyx.  Falls, 
kicks,  difficult    parturition,  constant  sitting  and  lesions    of  the 


DISEASES    OF   THE    VULVA.  173 

sacrum  are  common  causes.  In  some  cases  the  lesion  is  higher, 
affecting  the  origin  or  course  of  the  nerve  supplying  sensation  to 
the  integument  over  the  coccyx,  in  some  the  apparent,  in  others 
the  real  seat  of  the  pain.  The  nerves  involved  are  the  fifth 
sacral  and  the  coccygeal,  both  of  which  end  at  the  tip  or  pos- 
terior surface  of  the  coccyx.  Since  these  nerves  connect  with 
those  supplying  the  uterus,  uterine  and  ovarian  disease  may 
cause  a  pain  to  be  referred  to  the  coccyx  and  produce  coccydynia. 
Again,  the  same  segment  of  the  cord  which  supplies  sensation  to 
the  coccyx  supplies  the  uterus. 

The  PRINCIPAL  symptom  is  pain  on  the  slightest  pressure 
against  the  coccyx,  even  defecation  causing  pain.  In  most  cases 
there  is  a  constant  ache  or  pain  which  is  exaggerated  on  move- 
ment of  the  body  or  especially  from  sitting  long  in  one  position 
in  which  the  pressure  is  on  the  coccyx. 

The  treatment  should  be  directed  to  correcting  the  displace- 
ment of  the  coccyx.  This  is  accomplished  partly  by  external 
and  partly  by  internal  methods.  In  very  tender  cases  an  exter- 
nal treatment  should  be  used  until  the  parts  become  less  sensi- 
tive. The  internal  method  consists  of  introduction  of  the  finger 
into  the  rectum,  thereby  securing  such  a  grasp  on  the  coccyx 
that  reduction  is  made  possible.  In  other  cases,  such  as  a  sacral 
lesion,  uterine  displacement  or  those  in  which  the  pain  is  purely 
reflex,  the  particular  cause  must  be  ascertained  and  treated  ac- 
cordingly. 

TO  CORRECT  the  various  vaginal  disturbances,  remove  the 
lesions  found  and  direct  little  work  to  the  vagina  itself  since  the 
effect  not  the  cause,  in  most  diseases  is  located  there.  Do  not 
diagnose  by  symptoms  alone.  They  perhaps  help,  but  examine 
the  anatomy;  look  for  some  anatomical  abnormality;  this 
is  the  osteopathic  idea.     In  cases  of  prolapsus  of  the  vagina,  the 


174  DISEASES   OF   WOMEN. 

application  of  astringents  only  temporarily  increases  the  tonicity, 
the  walls  receiving  no  nourishment  from  them.  Their  use  can 
not  build  up  a  part  that  is  weakened  by  malnutrition.  It  is 
treating  a  symptom,  not  a  cause.  Sometimes  it  is  beneficial 
to  introduce  the  finger  and  smooth  out  the  folds  which  exist,  but 
the  principal  treatment  is  to  correct  the  lesion  found. 

Injuries  to  the  vaginal  walls  occur  in  some  cases  of 
labor,  however,  such  injuries  can  be  avoided  in  a  majority  of 
cases  by  our  treatment,  that  is  by  producing  relaxation  of  the 
constrictor  muscle  fibers  of  the  vagina  so  as  to  allow  the  fetal 
head  to  pass.  Sometimes  foreign  bodies  are  introduced  into  the 
vagina,  or  the  walls  injured  by  the  patient  in  the  practice  of 
masturbation  or  in  the  production  of  abortion.  The  writer  knew 
a  case  of  a  patient  that  made  a  practice  of  introducing  a  tallow 
candle  into  the  vagina  in  masturbating;  followed  by  a  peritonitis 
that  proved  almost  fatal. 

Awkward  or  forcible  coitus  often  results  in  laceration  or 
other  injury  of  the  vagina,  hymen  or  vulva.  If  the  vagina  is 
small  and  the  male  organ  very  large,  injury  of  the  vaginal  walls 
is  almost  sure  to  follow  the  first  coitus. 

The  IMPROPER  OR  unskillful  use  of  instruments,  or  drugs 
is  also  to  be  considered.  Too  frequent,  or  rather  the  use  of  too 
much  force  in  giving  digital  local  treatments,  may  injure  the 
walls. 

Douches.  A  vaginal  douche  consists  of  the  injection  of  a 
fluid  into  the  vagina  or  uterus.  It  consists  of  water,  hot,  luke- 
warm or  cold,  or  it  may  be  medicated.  It  is  a  practice  that  is 
indulged  in  by  women  for  the  sake  of  cleanliness  or  for  thera- 
peutical purposes,  and  has  become  such  a  common  one  that  it 
is  necessary  to  call  attention  to  some  of  the  evil  effects  that  fol- 
low its  use.     Daily  douches  are  recommended  by  physicians  if 


DISEASES    OF  THE    VULVA.  175 

there  is  pelvic  inflammation  or  leucorrhea.  The  theory  is  that 
the  inflammation  can  be  reduced  and  the  leucorrheal  discharge 
stopped,  apparently  forgetting  that  these  are  only  symptoms 
of  some  other  disturbance,  and  that  to  stop  the  discharge  with- 
out removing  its  cause,  only  makes  the  condition  worse.  Douches 
in  which  there  is  alum  or  witch  hazel,  are  also  advised  for  the 
above,  to  be  used  either  one  or  more  times  per  day.  I  have 
asked  patients  why  they  use  the  douche  so  often,  they  telling  me 
that  their  physician  advised  it  in  order  to  cure  the  prolapsus  or 
leucorrhea,  or  whatever  disease  condition  existed.  Perhaps  I 
will  cause  some  criticism  when  I  make  the  statement  that  hot 
water  douches  are  seldom,  if  ever  indicated,  and  in  most 
OASES  are  positively  HARMFUL  WHEN  USED  as  physicians  or- 
dinarily direct. 

Let  us  again  consider  the  secretion  of  the  vaginal  walls.  It 
is  acid,  germicidal  and  will  repel  microbic  invasion.  Examine  a 
normal  mucous  membrane;  it  is  self-cleansing,  self-purifying, 
and  will,  so  long  as  it  remains  normal,  take  care  of  itself.  Again, 
what  is  the  effect  of  water,  especially  lukewarm  water  as  is  gen- 
erally used,  upon  the  mucous  membrane?  It  washes  away  the 
secretion,  dilates  the  vessels,  slows  the  circulation  through  the 
membrane  and  impairs  the  secretion.  It  lessens  the  vitality 
of  the  parts,  leaving  them  in  a  lifeless  condition.  As  an  example, 
examine  the  fingers  of  a  washerwoman  after  she  has  hatl  her  hands 
in  water  for  a  little  while;  the  skin  of  the  palm  of  the  hands  and 
fingers  will  be  drawn  and  puckered. 

If  the  practice  of  using  douches  is  indulged  in  for  some  time, 
atony  of  the  vaginal  walls  must  follow  with  its  prolapsus, 
leucorrhea,  weakening  of  the  constrictors  and  a  distended  condi- 
tion of  the  fornices.  I  can  tell  in  most  cases,  by  local  examina- 
tion, whether  the  patient  has  used  douches  for  any  length  of  time; 


176  DISEASES    OF    WOMEN. 

since  it  causes  a  deepening  of  the  fornices,  leaving  a  cavity 
sometimes  over  an  inch  in  width  around  the  cervix.  No  won- 
der prolapsus  uteri  follows  this  condition. 

In  cases  of  putrid  discharges,  a  douche  is  sometimes  indi- 
cated, it  depending  on  the  individual  case.  This  is  given  for  the 
sake  of  cleanliness,  not  as  a  curative  agent.  Douches  of  a  weak 
solution  of  sodium  chloride  have  been  advised  by  some  osteo- 
pathic practitioners  for  leucorrheal  conditions.  They  may  be 
palliative,  in  that  they  lessen  the  amount  of  the  discharge,  but 
they  certainly  are  not  curative,  in  that  the  effect,  not  the  cause, 
is  treated. 

As  a  substitute  for  douches  as  therapeutical  agents  I  would 
offer  the  idea  of  correcting  the  anatomical  lesion  which  is  causing 
the  weakness  or  abnormal  discharge,  instead  of  applying  the 
water  to  the  symptom.  As  a  rule,  a  douche  of  some  sort  is  in- 
dicated after  the  menses  have  completely  stopped,  in  order  to 
remove  the  odor  which  clings  to  the  vagina  and  vulva,  but  not 
before,  as  the  flow  will  be  disturbed  by  it.  In  cases  of  malig- 
nant disease  a  wash  is  sometimes  used  if  the  odor  is  very  marked. 


AFFECTIONS  OF  THE  UTERUS.  177 

AFFECTIONS  OF  THE  UTERUS. 

THE  IMPORTANCE.  The  uterus  on  account  of  its  loca- 
tion, FUNCTION  and  the  ease  with  which  it  is  disturbed,  is  one 
of  the  most  frequently  diseased  organs  of  the  body.  It  may  be 
affected  in  various  ways;  by  being  displaced,  inflamed,  or  by 
growths  occuring  upon  it,  all  of  which  disturb  the  sympathetic 
nervous  system  which  is  so  intricately  and  abundantly  distri- 
buted to  and  around  it.  The  uterus,  being  the  organ  in  which 
gestation  occurs,  has  a  very  close  connection  with  the  vital  or- 
gans of  the  mother,  since  life  and  nourishment  are  carried  from 
one  to  the  other.  In  order  to  carry  nutrition  to  grow  a  fetus, 
the  nerve  and  blood  mechanism  must  be  very  highly  developed. 
Although  this  is  not  so  markedly  developed  before  pregnancy, 
yet  the  nerve  distribution  is  about  the  same,  a  few  new  nerves 
are  formed  during  the  pregnancy,  while  the  existing  nerves  are 
hypertrophied.  I  mention  this  in  connection  with  pregnancy 
because  that  is  the  special  function  of  the  uterus;  to  prepare  a 
place  for  the  impregnated  ovum,  to  develop  and  nourish  it  while 
in  utero,  and  then  expel  the  products  of  conception  at  the  end  of 
the  term.  Anything  which  disturbs  this  function  is  a  cause  of 
uterine  disease  since  it  interferes  with  nature's  laws. 

Again,  on  account  of  the  intimate  nervous  connection  be- 
tween the  uterus  and  other  organs,  they  may  be  affected  reflexly 
when  the  uterus  is  diseased.  All  organic  life  is  run  by  the  same  force ; 
this  force,  apparently  to  us,  is  derived  from  the  great  sympa- 
thetic nervous  system,  the  branches  of  which  follow  all  arteries 
and  veins,  controling  the  nourishment  and  function  of  each  organ. 
If  this  system  is  disturbed  in  one  place  the  next  weakest  point 
will  suffer  secondarily.     For  instance  if  the  stomach  is  weakened 

12 


178  DISEASES  OP    WOMEN. 

by  a  lesion  in  the  splanchnic  area,  a  displacement  of  the  uterus 
will  affect  the  stomach,  causing  various  troubles,  such  as  nausea, 
vomiting,  or  formation  of  gas.  Various  other  organs  are  affect- 
ed sympathetically,  that  is,  by  way  of  the  sympathetic  system, 
the  exciting  cause  being  a  disturbance  of  the  pelvic  organs  to 
which  the  sympathetic  system  is  most  widely  distributed,  and 
with  which  the  other  viscera  are  so  closely  connected. 

Relations  of  the  Uterus.  A  displacement  of  the  uterus 
will  directly  affect  the  adjacent  organs,  or  indirectly  as  men- 
tioned above,  the  distant  organs,  which  are  innervated  by  the 
same  nerve  force.  The  neighboring  organs  or  adnexa,  are  the 
bladder  in  front  and  below,  the  vagina  with  its  fornices  below, 
the  rectum  behind,  the  small  intestines  above,  and  on  either  side 
the  broad  ligaments,  vessels  and  nerves  to  the  uterus,  ovaries 
and  Fallopian  tubes.  There  is  no  vacant  space  or  cavity  in  the 
pelvis.  Every  crevice  and  fossa  is  filled.  The  uterus,  in  fact, 
is  surrounded  by  connective  tissue  filling  in  every  possible  space, 
which  helps  to  support  and  protect.  Muscle  fibers  penetrate  into 
the  connective  tissue  giving  it  strength,  contractility  and  elasticity. 
The  small  intestines,  being  in  relation  with  the  upper  or  back  part 
of  the  uterus,  exert  some  pressure  on  it.  The  uterus  becomes 
pathological  when  this  pressure     from  enteroptosis  is    marked. 

An  expulsive  force  acting  on  the  bowels  affects  the  position 
of  both  the  uterus  and  bladder.  Hence  in  straining  at  stool, 
if  the  uterine  supports  are  weak,  there  is  a  tendency  to  prolapsus 
of  the  uterus,  this  in  turn  affects  the  vaginal  walls,  Fallopian 
tubes  and  ovaries;  in  short,  a  disturbance  of  all  the  pelvic  organs. 
On  account  of  this  intimate  relation  existing  between  the 
different  pelvic  and  abdominal  organs  both  as  to  posi- 
tion and  function,  a  displacement  of  one  affects  all,  pro- 
ducing congestion  and  probably  inflammation. 


AFFECTIONS  OF  THE  UTERUS. 


179 


The  Normal  Position.  In  order  to  recognize  a  displacement  of 
the  uterus  it  is  first  necessary  to  acquaint  one's  self  with  the  normal 
position.  The  POSITION  of  the  normal  uterus  is  variable.  What 

WOULD  BE  REGARDED  AS  NORMAL  FOR  ONE  WOULD  BE  ABNOR- 
MAL FOR  ANOTHER.  There  seems  to  be  such  a  thing  as  a  normal 
abnormality;  that  is  the  uterus  may  be  apparently  or  in  reality 


Fig.  59. — The  normal  po.<ltion  of  the  uterus. 

very  much  displaced,  yet  the  patient  suffers  no  inconvenience 
from  it.  These  things  must  be  considered  in  making  up  a  cor- 
rect diagnosis. 

It  is  common  for  works  on  anatomy  and  gynecology  to  rep- 
resent the  uterus  as  having  a  straight   canal,  and  lying  midway 


ISO 


DISEASES    OF    WOMEN. 


between  the  symphysis  pubis  and  the  hollow  of  the  sacrum,  its 
axis  corresponding  to  that  of  the  inlet  of  the  pelvis,  that  is,  in  a 
position  of  a  very  slight  anteversion.  The  bladder  and  rectum 
are  wrongly  presupposed  to  be  distended,  thus  forcing  the  uterus 
into  the  position  which  is  seldom  seen  in  health,  or  at  least  it 
does  not  remain  so  for  any  great  length  of  time. 

The  NORMAL   POSITION  VARIES  with  the  distention   of  both 


Fig.  (50. — Movements  of  tlie  utenis  in  different  degrees  of 
dintention  of  the  bladder. 

the  bladder  and  rectum,  especially  with  that  of  the  bladder. 
Asid  :>  from  these  movements  it  has  a  rhythmical  movement,  due 
to  respiratory  action.  The  arc  of  mobility,  according  to  Reed, 
"may  vary  from  45  degrees  to  90  degrees."  A  uterus  may  be 
said  to  be  displaced  when  it  "ceases  to  manifest  these  normal 
variations  of  position,  and  when  it  persistently  remains  in  a  posi- 
tion distinctly  at  variance  with   the  one  which  it  should  occupy 


AFFECTIONS  OF  THE  UTERUS. 


181 


under  average  conditions."  Yet  on  the  other  hand  a  uterus 
with  TOO  GREAT  AN  ARC  of  mobiUty  may  be  said  to  be  displaced. 
This  refers  to  cases  in  which  the  uterus  can  be  moved  to  any 
position,  or  rather  one  that  changes  its  position  to  any  marked 
extent,  whenever  the  position  of  the  body  is  altered.  A  fixed 
uterus  whatever  its  position,  is  abnormal.  A  certain  amount 
OF  MOBILITY  of  the  UTERUS  IS  NECESSARY  to  the  functional  in- 
tegrity of  all  the  pelvic  viscera.  Theoretically,  if  the  patient  is 
in  an  erect  position  and  the  bladder  empty,  the  axis  of  the  uterine 


Fig.  61  — X,  Plane  of  pelvic  outlet.  Y,  Plane  of  peMc 
inlet.  1,  Symphisis.  2,  Sacrum.  3,  Rectum.  4,  Uterus. 
5,  Vagina.  6,  Bladder.  9,  Sigmoid  flexure  of  the  colon. 
10,  Utero  sacral  ligaments.    (Testut) 

canal  Ues  at  about  right  angles  to  the  vaginal  axis.  A  line  drawn 
from  a  point  midway  between  the  umbilicus  and  the  symphysis 
pubis  to  the  hollow  of  the  sacrum  will  fairly  represent  the  long 
axis  of  the  uterus,  the  fundus  being  about  on  a  level  with  the  brim 
of  the  true  pelvis.  The  canal  of  the  uterus  is  slightly  curved 
with  its  convexity  upward  and  backward.  Practically,  as 
stated  above,  many  a  normal  uterus,  in  fact  a  great  majority, 

DO   NOT   come   under  THIS   RULE. 


182  DISEASES   OF   WOMEN. 

With  the  patient  in  the  dorsal  position  introduce  the  index 
finger  of  the  right  hand  and  it  will,  when  carried  up,  come  in 
contact  with  the  conical  shaped  body  projecting  into  the  va- 
gina, which  is  the  cervix.  It  is  firmer  than  the  surrounding 
tissues,  its  tonicity  varying  in  different  cases,  a  congestion  as  in 
pregnancy  producing  softening;  a  deposit  of  fibrous  tissue,  pro- 
ducing hardening.  Its  direction  will  be  downward  and  back- 
ward; it  resting  on  the  ball  of  the  finger  when  well  introduced. 
If  the  cervix  is  in  line  with  the  vagina,  or  in  other  words,  if 
the  end  of  the  finger  comes  in  contact  with  the  end  of  the  cervix, 
it  indicates  a  retroversion,  or  a  cervical  anteflexion  since  the 
cervix  is  thrown  forward  in  such  displacements.  If  the 
end  of  the  cervix  is  high,  and  is  reached  with  difficulty,  it  is  prob- 
ably an  ANTEVERSiON.  In  typical  cases  of  flexion  the  cervix  is 
in  about  the  normal  position. 

The  POSITION  of  the  body  is  determined  by  bimanual  exami- 
nation, that  is,  with  the  examining  finger  of  the  right  hand  in  the 
vagina  and  with  the  other  hand  making  pressure  just  above  the 
symphysis  pubis.  (See  Fig.  51).  By  gently  raising  the  uterus 
with  the  internal  finger  the  impulse,  if  the  uterus  is  in  normal 
position,  will  be  transmitted  through  the  long  axis  of  the  uterus 
to  the  external  hand,  or  an  impulse  from  pressure  over  the  fundus, 
will  be  communicated  to  the  internal  or  examining  finger.  If 
slightly  anteverted  or  anteflexed,  or  if  the  uterus  is  carried  down- 
ward and  forward  by  external  pressure,  the  impulse  on  bimanual 
examination,  will  be  transmitted  through  the  uterus  antero- 
posteriorly,  that  is  flat  wise.  Even  in  the  normal  uterus,  if  it 
is  slightly  depressed  with  the  external  hand,  the  two  surfaces 
anterior  and  posterior,  instead  of  the  ends  of  the  cervix  and  fun- 
dus, are  palpated  between  the  two  hands. 

"  The  position  of  the  virgin  uterus  is  such  that  the  body  is 


AFFECTIONS  OF  THE  UTERUS.  183 

joined  to  the  cervix  at  an  obtuse  angle,  opening  downward  and 
forward,  so  that  on  an  internal  examination  one  can  feel  a  large 
part  of  the  anterior  surface  of  the  uterus  through  the  anterior 
vaginal  cul  de  sac."  If  the  uterus  can  not  be  felt  between  the 
two  examining  hands,  that  is  if  the  two  hands  can  be  so  closely 
approximated  that  each  examining  finger  or  hand  can  be  dis- 
tinctly felt  by  the  other,  it  indicates  a  backward  displacement, 
the  particular  form  of  which  is  determined  by  the  vaginal  and 
rectal  examination  by  which  both  ends  of  the  uterus  are 
located.  In  thin  subjects,  the  uterus  can  be  readily  outlined  by 
this  method,  but  in  the  obese  it  is  hard  to  locate  the  body  and 
the  diagnosis  must  be  made  from  the  vaginal  and  subjective  ex- 
aminations. 

NORMAL  SUPPORTS  OF  THE  UTERUS.  Several  fac- 
tors enter  into  the  composition  of  the  supports  of  the  uterus, 
it  being  maintained  for  the  most  part  by  the  pelvic  floor  of  which 
the  ligaments  are  regarded  as  a  part.  Normally  the  ligaments 
are  in  a  state  of  relaxation,  and  limit  the  normal  range  of  the 
movements  of  the  uterus;  backward  displacement  of  the  body 
is  resisted  by  the  round  ligaments;  backward  displacement  of 
the  CERVIX  by  the  utero-vesical  ligaments;  downward  and  for- 
ward displacements  by  the  sacro-uterine,  and  lateral  dis- 
placements by  the  broad  ligaments.  All  these  ligaments  con- 
tain MUSCLE  FIBERS  continuous  with  those  of  the  uterus,  hence 
in  a  relaxed,  enlarged  subinvoluted  uterus,  the  ligaments  will 
be  in  a  similar  condition,  thus  allowing  the  organ  too  free  move- 
ment or  improper  support. 

These  ligaments,  with  the  exception  of  the  sacro-uterine, 
could  not  support  the  uterus,  since  their  insertions  are  on  a  level 
with,  or  at  least  not  below  their  origin,  unless  the  organ  is  pro- 
lapsed.    All  the  ligaments  with  the  vesico-vaginal  septum,  con- 


184 


DISEASES   OF    WOMEN. 


stitute  a  suspensory  support  and  serve  to  anchor  the  uterus 
to  the  surrounding  tissues.  When  there  is  a  uterine  displace- 
ment, traction  is  brought  to  bear  upon  them,  which  is  accompanied 
by  a  dull  heavy  ache  or  dragging   down  sensation.     Some  de- 


PiG.  6i — Uterus  w  ith  pressure  equal  in  all   directions.    Pelvic   floor 

intact. 


scribe  it  as  a  constant  pulling  or  stretching  of  the  structures  of 
the  pelvis. 

When  no  extra  pressure  is  brought  to  bear  on  the  uterus, 
it  is  almost  entirely  supported,  according  to  Byford,  by  con- 


AFFECTIONS    OF   THE    UTERUS. 


185 


nective  tissue.     This  tissue  has  in  it  muscle  fibers,  hence  it  is 
especially  contractile  and  elastic. 

In  the  treatment  of  displacements,  one   of  the  objects  to  be 
attained  is  restoration   to  these  ligaments  and  connective  tissue, 


Fig.  63.— Uterus  with  pelvic  pressure  exerted  downward  from  lacerated 
pelvic  floor. 

of  normal  tone  and  contractility.  This  is  accomplished  prin- 
cipally by  external  treatment  correcting,  and  removing  the  causes 
that  weaken  it. 


186  DISEASES    OF    WOMEN. 

The  pelvic  floor,  with  its  muscles  and  Hgaments,  form  the 
REAL  SUPPORT  of  the  iiteius,  not  so  much  by  actual  contact,  the 
uterus  resting  on  it,  but  by  securely  closing  the  outlet  op 
THE  TRUE  pelvis,  thus  forming  a  closed  cavity.  In  this  cavity 
the  pressure  is  equal  in  all  directions  as  illustrated  in  Fig.  62. 
This  has  been  represented  by  a  pail  of  water;  while  the  bottom  of 
the  pail  is  intact,  pressure  is  as  great  upon  the  sides  of  the  pail  as 
on  the  bottom,  but  if  the  bottom  were  punctured,  nearly  all  the 
pressure  would  be  downward.  "The  contents  of  the  pelvis  are 
semifluid  and  of  nearly  equal  consistence."  From  this  it  would 
seem  that  the  pressure  would  be  about  equal  in  all  directions. 
If  the  vaginal  walls  are  held  closely  together  the  intrapelvic 
pressure  is  undisturbed,  but  if  the  floor  is  weakened  or  the  peri- 
neal body  lacerated,  air  will  probably  enter  the  pelvic  cavity 
thus  causing  the  pressure  to  be  exerted  downward. 

This  is  better  illustrated  by  considering  that  the  abdomen 
exerts  a  suction  force  on  the  pelvic  viscera  which  force  is  called 
the  retentive  power  of  the  abdomen.  This  is  illustrated  by  the 
physical  fact  that  "in  tapping  a  barrel  which  is  filled  with  a  liquid 
more  than  one  opening  has  to  be  made  before  the  contents  readily 
flow."  This  is  due  to  air  pressure,  the  sides  of  the  vessel  being 
unjdelding  to  the  external  air  pressure.  Thus  it  is  reasoned  that 
the  RETENTIVE  POWER  OF  THE  ABDOMEN  is  in  proportion  to  tlie 
strength  of  the  abdominal  walls.  The  weaker  and  more  re- 
laxed the  abdominal  walls,  the  greater  likelihood  of  a  displace- 
ment, or  in  other  words  the  abdominal  walls  form,  in  this 
way,  AN  important  support  of  the  uterus. 

The  vaginal  walls,  being  a  part  of  the  floor,  also  help  to  sup- 
port the  uterus.  A  weakness  of  the  walls  is  an  indication  and  is 
a  forerunner  of  prolapsus  uteri.  In  cystocele  and  rectocele,  which 
conditions  are  dependent  on  a  relaxed  vaginal  wall,  uterine  dis- 


AFFECTIONS  OF  THE  UTERUS.  187 

placements  are  almost  invariably  found.  Schultze  says,  "The 
muscular  and  connective  tissues  of  the  vagina  are  directly  con- 
tinuous with  the  same  tissues  of  the  uterus,  and  the  rigidity  of 
the  vagina  and  its  immediate  surroundings,  as  well  as  of  the  mus- 
cular tissues  and  fascia  of  the  pelvic  floor,  is  an  essential  factor 
in  securing  the  position  of  the  uterus." 

The  NORMAL  POSITION  of  the  organ  acts  as  a  preventative 
to  displacements  in  that  it  is  at  right  angles  to  the  vagina.  The 
pressure  of  the  abdominal  viscera  forces  it  farther  into  anteversion. 
On  account  of  this  fact  the  position,  at  least,  tends  to  prevent 
"falling  of  the  womb"  or  prolapsus. 

In  considering  the  supports  of  the  uterus  all  of  them  must 
be  CONSIDERED  together  since  they  act  together.  Not  the 
pelvic  floor  alone,  nor  the  ligaments  of  themselves  support  the 
uterus ;  but  the  pelvic  floor,  the  ligaments,  the  intra-pelvic  pressure, 
the  action  of  the  intestines,  the  contraction  of  the  diaphragm 
and  the  intra-abdominal  pressure,  all  unite  to  keep  the  uterus 
in  its  proper  place. 

Varieties  of  Displacements.  The  uterus  may  be  displaced  back- 
ward, forward,  downward  to  one  side  or  upward,  the  last  named 
displacement  is  properly  called  an  ascent,  or  mal-location  of 
the  uterus.  The  writer  has  seen  a  few  cases  of  this  form,  it  being 
a  comparatively  rare  kind  of  displacement. 

The  BACKWARD  displacements  are  retroversion  and  re- 
troflexion. Forward  displacements  are  called  anteversion 
and  anteflexion  The  downward  displacement  is  called  pro- 
lapsus, or  if  the  displacement  is  complete  it  is  called  procidentia. 
The  lateral  displacements  are  called  latero-version  or  latero- 
flexion;  when  to  the  right  dextro-,  if  to  the  left,  sinistro-lateral 
flexion  or  version .  Often  there  is  a  combination  of  some  of  these 
displacements,  the  most  common  of  which  is  an  anteflexion  com- 


188  DISEASES    OF   WOMEN, 

plicated  by  a  retroversion.  The  anteflexion  is  usually  primary. 
The  walls  undergo  changes  which  make  straightening  of  them 
impossible.  If,  while  in  this  condition,  the  patient  has  a  fall  or 
anything  which  suddenly  changes  the  intra-abdominal  pressure, 
it  will  cause  the  uterus  to  retrovert,  although  it  retains  its  bent 
form.  On  examination  the  concavity  can  be  felt  through  the 
anterior  fornix,  although  the  body  is  back. 

GENERAL  SYMPTOMS  OF  A  DISPLACEMENT.  The  most 
common  symptoms  which  belong  to  all  displacements  are  back- 
ache, a  SENSE  of  HEAVINESS  in  the  pelvis  and  lower  limbs,  inter- 
ference with  walking  or  standing,  pain  referred  to  the  pelvic 
organs  and  limbs,  such  as  cramping,  sciatica  and  coldness,  and 
MENSTRUAL  DISTURBANCES,  either  dysmenorrhea  or  menorrhagia. 
Any  displacement  affects  the  pelvic  circulation  since  the  uterus 
is  so  very  vascular  and  the  blood  pressure  low.  The  ovaries 
are  very  commonly  affected  by  any  form  of  displacement.  The 
characteristic  pain  or  cramp  in  the  region  of  the  ovary  is  the 
most  important  of  the  symptoms  resulting  from  ovarian  dis- 
turbances. Tenderness  is  found  on  palpation  of  the  lower  part 
of  the  abdomen,  particularly  in  the  iliac  fossae,  the  sacro-iliac 
synchondrosis  and  at  or  near  the  spine  of  fifth  lumbar  vertebra. 

The  reflex  symptoms  are  headache,  suboccipital  and  ver- 
tical, aching  between  the  shoulders,  nervousness,  spinal 
irritation  or  tenderness,  stomach  troubles,  neuralgias  and 
forms  of  paralysis,  hysteria  and  neurasthenia.  These  symp- 
toms belong  to  nearly  all  displacements,  while  special  symptoms 
indicate  the  particular  kind  of  displacement. 

PROLAPSUS  OF  THE  UTERUS.  Prolapsus  uteri  is  a  con- 
dition in  which  the  uterus  sinks  to  a  lower  level  in  the  pelvis 
than  is  found  in  a  normal  subject,  which  is  accompanied  by  a  re- 
laxation of  the  pelvic  floor,  prolapsus  of  the  bladder  and  vagina. 


AFFECTIONS  OF  THE  UTERUS.  189 

There  are  several  forms  which  are  classified  according  to  their 
degrees.  The  mildest  type,  characterized  by  some  retrover- 
vesion  and  descent,  constitutes  the  first  degree.     If  the  cervix 

APPROACHES  THE  VAGINAL  OUTLET  it  is  Called  the  SECOND  DEGREE, 

and  if  the  uterus  is  outside  the  vaginal  orifice  it  is  called  the 


Fig.  64.— Prolapsus  uteri. 


iHiRD  DEGREE,  or  procidentia.  These  forms  or  degrees  of  pro- 
lapsus run  into  each  other,  it  being  impossible  to  differentiate 
between  them  unless  they  are  typical  forms. 


190  DISEASES    OF    WOMEN. 

Prolapsus  is  the  most  common  of  all  uterine  displacements, 
as  well  as  the  first  displacement  mentioned  in  literature.  Among 
the  laity  it  is  called  ''falling  of  the  womb,"  or  "female 
weakness"  and  its  importance  is  understood  by  most  patients 
suffering  with  it.  Most  of  them,  as  well  as  physicians,  so 
appreciate  its  significance  that  almost  every  conceivable  remedy 
has  been  applied,  ranging  from  medicinal  applications  to  artifi- 
cial supports. 

Some  of  the  cases  of  prolapsus  are  obscure,  if  examined  in 
the  usual  way,  but  if  examined  in  the  erect  posture  the  pro- 
lapsus, as  well  as  the  degree  can  then  be  definitely  ascertained. 
Prolapsus  is  nearly  always  accompanied  by  retro-displacement, 
it  being  almost  impossible  for  the  uterus  to  prolapse  without  a 
retroversion,  since  its  axes  is  at  right  angles  to  the  vaginal  axis 
and  must  turn  so  that  the  axes  will  correspond.  Retroversion, 
to  such  a  degree  that  the  axes  of  the  uterus  and  vagina  coincide, 
is  called  the  first  degree  of  prolapsus.  Thus  the  pathological 
events  of  prolapsus  uteri  taken  in  their  sequence  are  (1)  weak- 
ening of  uterine  supports,  (2)  retroversion  of  the  uterus,  (3) 
descent  of  uterus,  (4)  commencing  prolapsus  of  vagina,  (5) 
commencing  inversion  of  the  vagina,  (6)  prolapsus  of  bladder 
and  (7),  the  above  named  conditions  gradually  increasing  in 
intensity,  especially  the  sinking  of  the  uterus  lower  and  lower 
until,  unless  checked,  procidentia  takes  place.  There  is  con- 
gestive HYPERTROPHY  of  the  uterus,  especially  of  the  cervix. 
In  some  this  is  so  marked  that  the  term  hypertrophic  elongation 
or  pseudo-prolapsus  has  been  applied. 

CAUSES.  Prolapsus  uteri  is  due  to  one  of  three 
things;  either  a  weakness  of  the  supports  or  increase  in  size  of 
the  parts  to  be  supported,  or  sudden  increase  of  intra-abdominal 
pressure.     Thus  it  may  come  on  suddenly,  as  a  result  of  a  severe 


AFFECTIONS  OF  THE  UTERUS.  191 

strain  or  fall,  which  suddenly  increases  the  intrapelvic  pressure. 

Weakening  of  the  pelvic  floor  implies  that  the  nerve  sup- 
ply is  interfered  with,  a  condition  of  malnutrition  existing. 
The  NERVE  supply  is  principally  from  the  anterior  sacral  nerves, 
with  the  PUDic  also  sending  some  branches  to  it.  The  pudic 
nerve  being  the  nerve  of  sensation  in  coition,  loss  of  sexual  vigor 
from  excessive  venery  or  from  a  lesion  affecting  it,  will  help  weak- 
en the  floor,  since  the  pudic  nerve  is  distributed  to  the  floor. 
Tracing  the  sacral  nerves  to  their  origin  and  noticing  their  rela- 
tions and  where  they  make  their  exit,  it  can  be  readily  seen  that 
a  displacement  of  the  lumbar  vertebrae,  sacrum,  innomi- 
nate bones,  or  coccyx,  will  affect  them  either  by  direct  pressure 
or  indirectly  by  muscular  contraction.  The  lumbar  region  in 
many  is  posterior  with  muscular  lesions;  in  some  the  spine  is 
rigid,  in  others  unduly  relaxed.  This  relaxation  extends  to  the 
pelvic  structures  and  abdominal  wall.  In  other  cases  in  which 
the  spine  is  rigid,  the  intervertebral  discs  are  thinned  from 
pressure  and  the  vertebrae  approximated,  the  latter  of  which  re- 
sults in  a  lessening  in  size  of  the  intervertebral  foramina. 
This  condition  is  soon  followed  by  an  impairment  of  the  nerves 
and  vessels  in  relation,  which  soon  results  in  paresis  or  weaken- 
ing of  the  pelvic  and  abdominal  viscera. 

A  weakening  of  these  nerves  causes  a  weakening  of  the  mus- 
cles supplied  by  them,  since  the  strength  of  the  muscle  depends 
upon  the  amount  of  the  nerve  force  going  to  it.  Take  for  in- 
stance, an  insane  man  during  a  paroxysm;  it  requiring  several 
men  to  control  him,  otherwise  one  man  can  easily  hold  him  dur- 
ing the  quiescent  stage.  The  man  has  the  same  muscles  during 
each  stage,  but  the  explosion  of  nerve  force  in  the  one.  increases 
to  a  marvelous  extent  the  muscular  power.  Applying  this  to 
the  pelvic  floor  the  muscles  may  still  retain  their  volume,  but  if 


192  DISEASES   OF    WOMEN. 

their  food  or  nerve  force  is  shut  off,  they  weaken,  letting  to  a 
lower  level  the  parts  which  should  be  supported  by  them.  This 
is  the  IMPORTANT  CAUSE  of  prolapsus  and  one  not  mentioned  in 
medical  literature. 

The  floor  is  frequently  injured  and  weakened  by  lacera- 
tion during  deliver}^,  this  laceration  usually  taking  place  in  the 
KEY  STONE  of  the  pelvic  floor,  or  perineal  body.  This  is  a  condi- 
tion that  should  not  be  permitted  to  happen  in  cases  in  which  no 
deformitiy  exists,  and  I  consider  it  carelessness  or  ignorance  if  it 
is  permitted  to  occur.  After  the  perineal  body  is  torn  it  hinders 
or  prevents  approximation  of  the  vaginal  walls,  permitting  air 
to  enter  the  pelvic  cavity,  which  normally  is  air  tight.  Even  in 
coition,  or  digital  examination,  no  air  enters  on  account  of  the 
vaginal  walls  closing  so  completely  around  the  part  introduced. 
If  this  injury  exists  the  walls  are  separated  and  the  equilibrium 
of  the  pelvic  contents  destroyed,  the  pressure  being  exerted 
downward  instead  of  being  exerted  equally  in  all  directions. 
Laceration  of  the  perineum  weakens  the  pelvic  floor,  since  it  sets 
up  a  congestion  or  inflammation  which  disturbs  nutrition.  The 
floor  is  engorged  with  venous  blood,  its  specific  gravity  increased 
and  it  sinks  to  a  lower  level.  Prolapsus  of  the  vaginal  walls, 
pulls  the  cervix  down  by  exerting  traction  on  it.  This  brings  the 
uterus  into  a  position  of  retroversion,  which  position  is  followed 
almost  invariably  by  descent  or  prolapsus  uteri. 

Weakening,  with  relaxation  and  stretching  of  the  utero- 
sacral  ligaments,  is  one  of  the  most  important  of  single  causes  of 
prolapsus.  The  function  of  these  ligaments  is  to  hold  the  lower 
part  of  the  uterus  in  position,  that  is  up  and  back.  It  does  this 
by  suspension;  the  ligaments  being  almost  vertical,  when  pa- 
tient is  in  the  erect  posture.  When  the  ligaments  relax,  the  cervix 
drops  forward, and  down  ward, thro  wing  the  uterus  into  retroversion. 


AFFECTIONS  OF  THE  UTERUS.  193 

This  change  in  the  position  of  the  uterus  is  primary  to,  and  takes 
place  in  nearly  all  cases  of  retroversion  and  prolapsus.  These 
ligaments  have  muscle  fibers  which  are  supplied  by  the  anterior 
division  of  the  sacral  nerves  in  relation.  Hence  lesions,  by  affect- 
ing these  nerves,  are  important  causes  of  prolapsus  since  their 
relaxation  is  due  to  an  impairment  of  nerve  force  or  nutrition, 
this  being  the  usual  effect  of  lesions  on  motor  nerves.  Kelly 
has  described  relaxation  as  the  most  important  of  all  in- 
juries of  the  perineum  and  pelvic  floor. 

Increase  in  weight  of  the  uterus  is  a  cause  of  prolapsus.  In 
cases  of  subinvolution  in  which  the  condition  has  existed  for 
sometime,  the  continual  downward  pressure  will,  in  time,  stretch 
and  weaken  the  supports,  and  prolapsus  will  result.  If  the  pa- 
tient, after  deliverj^  gets  up  before  involution  is  well  under  way, 
the  uterus,  being  already  in  a  retroverted  condition,  will  be  forced 
downward,  sometimes  resulting  in  a  serious  prolapsus.  In  these 
cases  there  is  also  a  weakening  of  the  vaginal  walls  from  subin- 
volution. If  in  case  of  parturition  the  uterus  is  left  in  the  hollow 
of  the  sacrum,  the  thickened  ligaments  will  become  permanently 
stretched,  thus  losing  their  contractile  power,  leaving  the  uterus 
in  this  retroverted  and  prolapsed  condition. 

In  fibroid  tumors  of  the  uterus  it  may  be  forced  down  by 
sheer  weight,  although  the  tumor  sometimes  develops  upward 
and  draws  the  uterus  with  it.  The  writer  recalls  a  case  of  a  lady 
sixty-five  years  of  age  who  suffered  with  procidentia  caused  by 
a  subperitoneal  fibroid  tumor.  The  tumor  caused  few  of  the 
ordinary  discomforts  which  usually  attend  fibroids;  the  uterine 
displacement  with  a  few  pressure  pains  being  the  most  noticeable. 

Pressure,  exerted  on  the  pelvic  contents  by  the  wearing  of 
heavy  skirts  or  tight  clothing,  produces  congestion  of  the  uterus, 
increases  its  specific  gravity,  and  as  a  result,  it  is  forced  farther 

13 


194  DISEASES   OF   WOMEN. 

down  in  the  pelvis.  In  enteroptosis  the  condition  is  similar,  that 
is,  increased  pelvic  pressure  and  interference  with  the  venous 
return. 

Sudden  falls  or  strains  derange  the  intra-pelvic  and  intra- 
abdominal pressure  and  if  the  bladder  is  full  at  that  time,  it  may 
result  in  retroversion  and  prolapsus.  One  of  the  worst  cases  of 
prolapsus  that  the  writer  ever  treated  was  the  result  of  a  back- 
ward fall,  bringing  on  an  acute  retroversion  and  prolapsus. 
Straining  at  stool  also  increases  the  intra-pelvic  pressure,  and 
tends  to  force  the  uterus  downward.  This  is  especially  true  if 
done  within  a  few  weeks  after  labor,  that  is  during  thepuerperium, 
and  constitutes  a  common  exciting  cause  of  prolapsus.  The 
uterus  at  that  time  is  large  and  heavy  and  the  pelvic  floor  weak- 
ened, which  conditions  are  aggravated  by  constipation  which 
usually  complicates.  With  such  conditions,  straining  at  stool 
when  patient  is  in  the  squatting  posture  will  almost  invariably 
bring  on  descent  of  the  uterus.  To  avoid  this  in  a  great  meas- 
ure, advise  the  patient  to  use  a  bed  pan  for  several  weeks  after 
labor. 

A  too  ROOMY  pelvis  tends  to  permit  of  displacement,  descent 
being  the  most  common.  Neglect  of  the  evacuation  of  the  bowels 
and  the  bladder  increases  the  tendency  to  prolapsus  whenever 
the  patient  strains  or  carries  a  heavy  weight.  Stooping  over  a 
cradle  and  repeatedly  lifting  a  large  fat  baby  is  almost  sure  to 
produce  displacement  of  the  uterus,  if  oft  repeated,  within  a 
year  or  so  after  confinement.  The  condition  of  the  uterine  liga- 
ments and  supports  determines  the  frequency  of  it.  The  awkward 
position,  the  strain  and  the  condition  of  weakness  antl  relaxa- 
tion of  all  the  pelvic  contents,  make  it  possible.  Also  the  stooping 
posture  lessens  the  inclination  or  obliquity  of  the  pelvis,  thus 
allowing  the  abdominal  contents  to  press  more  directly   on    the 


AFFECTIONS  OF  THE  UTERUS.  195 

uterus.  Severe  paroxysms  of  coughing  or  violent  action  of  the 
abdominal  or  other  muscles,  such  as  in  epileptic  convulsions, 
force  the  uterus  down,  since  such  things  increase  the  intra-abdomi- 
nal pressure. 

In  certain  occupations  in  which  the  patient  is  on  her  feet  a 
great  deal  and  when  there  is  malnutrition  and  poor  air,  there  is 
a  tendency  to  prolapsus  of  the  uterus.  This  is  proven  by  the 
number  of  school  teachers  and  shop  girls,  who  have  this  form  of 
uterine  displacement. 

Pressure  directed  on  the  uterus  from  above  is  a  prolific  cause 
of  prolapsus.  This  pressure  is  the  result  of  many  causes,  belts, 
tight  clothing,  and  heavy  skirts  supported  by  bands  are  the  most 
important.  Waitresses  in  hotels  usually  have  prolapsus  or  a 
backward  displacement  on  account  of  the  way  they  carry  the 
platters,  this  tilting  the  pelvis,  thus  throwing  the  strain  on 
the  abdominal  muscles,  which  increases  the  tendency  to  pro- 
lapsus. If  the  uterus  is  small  and  the  outlet  is  large,  such  as  is 
found  in  atrophy  of  the  vaginal  walls,  it  may  be  forced  down- 
ward. This  is  a  condition  found  in  the  aged  and  is  supposed  to 
be  due  to  senile  atrophy  of  the  vagina.  The  writer  recently  saw 
a  case  of  complete  procidentia  which  had  come  on  suddenly  at 
the  menopause;  it  caused  comparatively  little  pain,  she  replacing 
the  organ  some  ten  to  twenty  times  each  day.  The  cervix  was 
so  excoriated  that  it  appeared  to  be  of  a  cancerous  nature.  This 
form  of  prolapsus  yields  very  slowly  to  treatment  on  account  of 
the  age  and  the  relaxed  condition  of  the  supports. 

SYMPTOMS.  The  severity  of  the  symptoms  does  not  de- 
pend upon  the  degree  of  the  displacement,  but  on  the  nervous 
condition  of  the  patient,  mode  of  onset,  amount  of  inflammation, 
length  of  standing  and  organs  involved.     I  have  seen  cases  of 

COMPLETE    PROCIDENTIA,    which    CAUSED   VERY   LITTLE   PAIN,   whilc 


196  DISEASES   OF   WOMEN. 

on  the  other  hand  cases  of  prolapsus  of  the  first  degree 
caused  the  patient  great  suffering,  and  almost  unbearable 
pain  and  nervousness. 

If  the  prolapsus  comes  on  gradually  there  are  no  character- 
istic symptoms  in  the  early  stages.  If  brought  on  suddenly 
the  symptoms  are  acute  and  demand  immediate  attention.  In 
ordinary  cases  the  patient  complains  of  sensation  of  weight  or 
heaviness  in  the  pelvis;  this  is  increased  by  the  patient  standing 
on  her  feet  or  walking  any  distance,  and  is  worse  toward  evening, 
that  is  after  standing  for  several  hours.  There  also  exists  rec- 
tal and  vesical  irritation  produced  by  the  traction  exerted  on  the 
vesico-  and  sacro-uterine  ligaments. 

Pain  is  referred  to  the  interscapular  region,  which  increases 
when  the  patient  uses  the  arms.  This  pain  is  described  as  an 
ache  which  is  nearly  constant,  and  is  dull  in  character.  The 
possible  explanation  of  it  is  that  the  mammae,  which  constitute 
a  part  of  the  generative  system,  are  supphed  with  nerves  which 
have  their  spinal  center  in  this  region;  and  a  disturbance  of  one 
part,  viz.,  the  uterus,  would  reflexly  affect  the  other,  which  in 
this  case  is  manifest  by  an  ache  in  the  region  supplied  by  nerves 
which  come  from  the  same  segment  of  the  cord  that  supplies  the 
mammary  glands.  The  pain  is  sometimes  transmitted  to  the 
limbs,  either  producing  an  aching  or  cramping  of  the  muscles. 
Cramping  of  the  calf  of  the  leg  is  possibly  due  to  the  disturb- 
ance of  the  pudendal  branch  of  the  small  sciatic. the  impulses  being 
reflected  over  the  small  sciatic  to  the  calf  of  the  leg  where  the 
nerve  terminates. 

Menstrual  disturbances  result  from  prolapsus;  Menorrha- 
gia being  the  most  common.  The  uterus  is  badly  congested  and 
the  blood  circulates  very  slowly.  This  surplus  of  venous  blood 
finds  escape  at  the  menstrual  time  in  the  form  of  a  menorrhagia. 


AFFECTIONS  OF  THE  UTERUS.  197 

Not  only  is  the  uterus  congested  but  the  circulation  of  the  vaginal 
walls  is  affected.  This  interferes  with  secretion  and  produces 
a  hypersecretion  or  leucorrhea.  Leucorrhea  depends  upon 
CONGESTION,  and  since  congestion  results  from  prolapsus  it  is 
easy  to  see  how  naturally  leucorrhea,  both  uterine  and  vaginal, 
would  accompany  this  form  of  displacement.  Dysmenorrhea 
occurs  in  some  cases,  it  being  due  to  (1)  clotted  blood,  the 
uterus  having  to  go  into  labor  to  expel  the  clots,  or  (2)  impair- 
ment OF  THE  EXPELLANT  forces  of  the  uterus,  or  (3)  pathological 
congestion  of  the  uterine  substance  by  which  the  blood  pressure 
is  raised  to  the  painful  point,  any  or  all  of  which  occur  in  typical 
cases  of  prolapsus. 

Prolapsus  of  the  uterus  produces  a  general  weakness  of 
the  body.  This  is  a  result  of  disturbances  of  nutrition  and  loss 
of  nerve  force,  and  partly  the  result  of  worrying  over  the  condi- 
tion, as  falling  of  the  womb  is  a  condition  which  is  dreaded  by 
all  women. 

The  patient  is  unable  to  exercise  without  getting  greatly 
fatigued.  There  is  palpitation  of  the  heart,  shortness  of  the 
breath  and  inability  to  lift  anything  heavy.  Rectocele  and 
cystocele  often  accompany  prolapsus,  especially  if  the  vaginal 
walls  are  very  much  affected,  and  they  are  always  affected  in 
cases  in  which  the  prolapsus  is  very  marked  or  of  very  long  stand- 
ing. These  conditions  affect  the  rectum  and  bladder,  often 
causing  painful  and  severe  functional  disturbances,  such  as  tenes- 
mus, rectal  pain  or  irritation,  coccydynia,  and  disturbances  of 
defecation. 

In  procidentia  the  exposed  part  may  become  chafed  and 
irritated  from  friction  of  the  clothing  in  walking,  causing  extreme 
suffering  and  giving  it  a  malignant  appearance. 

PHYSICAL  SIGNS.     The  above  symptoms  are  only  indica- 


198  DISEASES    OF   WOMEN. 

tions  of  prolapsus,  prompting  us  to  make  a  local  examination  to 
clear  up  the  diagnosis.  Should  there  be  the  first  degree  of  pro- 
lapsus, the  finger  passed  up  through  the  vagina,  will  meet  with 
the  cervix  low  down  and  in  a  line  corresponding  with  the  vaginal 
axis.  The  body  will  be  found  backward,  indicating  a  position 
of  retroversion.  This  is  ascertained  by  palpating  the  body  or 
FUNDUS  through  the  posterior  fornix  or  rectum  and  by  not 
FINDING  the  uterus  on  palpation  through  the  anterior  fornix. 
Also  on  this  account,  that  is  the  uterus  being  back,  the  hands  can 
be  approximated  immediately  behind  the  pubes  and  anterior 
to  the  uterus;  that  is  each  hand,  one  being  internal  and  the  other 
external,  can  be  palpated  by  the  other.  The  vaginal  walls  are 
usually  very  smooth  and  covered  with  transverse  folds,  not  rugae. 

If  the  second  degree  of  prolapsus  exists,  the  cervix  will  be 
found  at  the  vaginal  orifice,  which  is  best  ascertained  in  the  sitting 
or  erect  posture.  The  body  is  turned  backward  and  the  upper 
portion  of  the  vaginal  walls  rolled  downward ;  the  uterus  is  grasped 
by  the  sphincter  muscles  and  in  conjunction  with  the  uterine 
ligaments  a  complete  prolapsus  is  prevented,  unless  there  is  ex- 
cessive weakness.  Complete  prolapsus  is  diagnosed  by  inspec- 
tion and  palpation.  The  os  can  be  seen  and  the  different  parts 
of  the  uterus  can  be  palpated,  making  the  diagnosis  certain. 

DIAGNOSIS.  Any  of  the  varieties  of  prolapsus  may  some- 
times be  confounded  with  polypi,  inversion  of  the  uterus  or  hyper- 
trophy and  elongation  of  the  cervix,  which  produces  a 
pseudo-prolapsus.  In  a  polypus,  the  shape  and  con- 
sistency of  the  presenting  body  is  different  and  there  is  the  ab- 
sence of  the  cervix  and  os.  Inversion  is  diagnosed  by  the  ab- 
sence of  the  OS  and  cervix,  the  larger  end  or  fundus,  presenting. 
The  COVERING  of  the  presenting  part  will  be  different;  in  prolap- 
sus it  is  glistening;  in  inversion  it  is  raw,  bleeding  and  irritable. 


AFFECTIONS  OF  THE  UTERUS.  199 

Inversion  occurs  at  or  immediately  after  childbirth,  the  history 
helping  to  make  a  diagnosis.  In  hypertrophy  of  the  cervix, 
bimanual  examination,  and  the  use  of  the  sound,  will  clear  up 
the  diagnosis.  If  the  uterine  canal  is  found  very  much  elongated 
it  is  probably  a  condition  of  hypertrophy  of  the  cervix.  The 
diagnosis  of  prolapsus  really  depends  on  locating  the  cervix  at  a 
lower  level  than  normal  and  finding  the  fundus  backward  and 
downward,  this  being  done  by  digital  and  bimanual  examination. 
THE  EFFECT  ON  THE  ADJACENT  ORGANS.  The  organs 
ADJACENT  to  the  uterus  are  the  bladder,  rectum,  Fallopian  tubes 
and  the  ovaries.  The  bladder  is  pulled  down  by  the  vesico- 
uterine ligaments  until  quite  a  noticeable  cystocele  is  formed. 
The  tension  resulting  from  the  continued  traction  irritates  it, 
and  is  the  cause  of  frequent  micturition.  The  urethra  is  bent 
on  itself  and  on  this  account  complete  evacuation  of  the  bladder 
does  not  occur  at  micturition.  This  is  accompanied  or  followed 
by  decomposition  of  the  residual  urine  which  gives  rise  to  cystitis, 
pyelitis,  or  uremic  symptoms.  Traction  is  exerted  on  the  rectum 
by  the  retco-and  sacro-uterine  ligaments,  producing  an  irritation 
which  often  results  in  tenesmus.  The  Fallopian  tubes  are  drawn 
downward,  pulling  the  ovaries  with  them.  This  produces  con- 
gestion of  the  ovaries  and  tubes,  causing  pain  and  menstrual 
disorders.  Immediately  behind  the  uterus  are  the  roots  of  the 
sciatic  nerve,  the  sympathetic  plexuses  and  ganglia  and  the  an- 
terior divisions  of  the  sacral  nerves.  The  obturator  nerve  is 
also  near,  as  well  as  the  secondary  plexuses  derived  from  the 
hypogastric  plexus.  The  ligaments  are  put  on  a  stretch;  and  in 
the  case  of  the  broad  ligaments,  between  the  laj^ers  of  which 
passes  all  the  blood  to  and  from  the  uterus,  a  considerable  vascu- 
lar disturbance  is  produced,  usually  in  the  form  of  a  venous  con- 
gestion.    The  force  exerted  by  the  prolapsed  uterus  pulling  on 


200  DISEASES   OF   WOMEN. 

the  different  ligaments  produces  a  pain  which  is  referred  to  the 
BACK,  or  pressure  is  exerted  directly  on  the  nerves  causing  neu- 
ralgia, or  other  disturbances  of  the  limbs.  The  vaginal  walls 
are  reduplicated,  especially  so  in  the  worst  forms  of  prolapsus. 
The  pouch  of  Douglas  is  elongated  and  pulled  down  and  with  it, 
in  most  cases  of  marked  prolapsus,  a  part  of  the  small  intestines 
and  peritoneum,  giving  rise  to  a  condition  called  enterocele. 
In  short,  every  adjacent  organ  or  structure  is  more  or  less  affect- 
ed by  prolapsus  on  account  of  pressure  directly  on,  or  interfer- 
ence Avith  circulation  and  nerve  supply,  to  such  adjacent  tissues. 

The  complications  of  prolapsus  are  congestion  or  inflamma- 
tion of  the  uterus  and  its  appendages,  such  as  metritis,  salpingi- 
tis, ovaritis  and  peritonitis.  Congestive  hypertrophy  occurs 
in  most  chronic  cases.  Cystocele  and  rectocele  are  common; 
sterility,  leucorrhea  and  disorders  of  bladder  and  rectum  are 
found  in  many  cases.  Sciatica  is  one  of  the  common  and  dis- 
agreeable complications.  The  lower  limbs  and  feet  are  cold 
and  sometimes  the  ankles  are  edematous  and  the  veins  varicose. 
The  patient  complains  of  a  heavy,  achy,  tired  feeling  to  such  an 
extent  that  she  can  with  difficulty  draw  one  limb  after  another. 

THE  PROGNOSIS  depends  upon  the  condition  of  the  uterus 
and  vaginal  walls,  the  character  of  the  complication  and  whether 
or  not  she  can  take  care  of  herself  during  the  treatment.  In  long 
standing  cases  in  which  the  entire  system  is  poorly  nourished,  a 
cure  will  be  slow ;  in  recent  cases  in  which  the  tonicity  of  the  floor 
or  part  of  it  is  retained,  the  prognosis  is  better.  In  cases  in  which 
the  displacement  is  the  result  of  causes  which  have  been  in 
operation  for  a  long  time,  the  outlook  is  poor.  In  cases  in 
which  the  trouble  came  on  suddenly,  such  as  the  result  of  a  fall, 
the  prognosis  is  good.  In  the  first  class  of  cases  the  supports 
have  to  be  strengthened  by  correcting  the  bony  lesions,  local 


AFFECTIOXS  OF  THE  UTERUS.  201 

TREATMENT  BEING  SECONDARY.  In  the  second  class  of  cases  a 
cure  is  usually  effected  by  simply  replacing  the  organ.  If 
the  vagina  is  large  and  the  pelvic  floor  relaxed,  the  case  is  a  hard 
one  to  cure,  and  especially  so  if  the  patient  has  to  be  on  the  feet 
a  great  deal.  I  regard  it  as  one  of  the  hardest  of  uterine  dis- 
placements to  cure;  first,  on  account  of  the  nature  of  the  causes, 
and  second,  on  account  of  its  position,  which  allows  it  to  drop 
lower  when  the  patient  strains,  or  from  pressure  in  ordinary  res- 
piration, it  being  acted  upon  directly  by  force  of  gravity.  If 
the  cause  is  apparent  the  prognosis  is  more  favorable,  but  in  a 
great  many  cases  the  primary  cause  is  obscure,  making  the  prog- 
nosis uncertain. 

SUDDEN  PROLAPSUS  may  come  on  from  any  violent  effort 
in  which  the  abdominal  muscles  are  forcibly  contracted,  or  if 
the  intra-abdominal  pressure  is  suddenly  increased  from  any 
cause  whatever.  If  the  uterus  is  diseased  or  the  supports  weak- 
ened, a  sudden  displacement  will  usually  take  place  if  the  patient 
has  a  fall  or  lifts  any  heav}-  weight.  In  an  instant  the  patient 
feels  that  something  has  given  away  ^^dthin  her,  becomes  pros- 
trated and  suffers  pain  of  an  expulsive  character.  Sometimes 
the  stomach  wall  be  affected  reflexly,  causing  nausea  and  vomit- 
ing. If  the  displacement  is  not  corrected  at  once,  the  irrita- 
tion will  spread  to  the  adjacent  parts  and  inflammation,  such  as 
peritonitis,  will  set  in  with  its  attending  evils. 

TREATMENT.  In  taking  up  the  treatment  of  prolapsus, 
the  prophylactic  treatment  will  be  considered  first.  The  pro- 
phylactic treatment  of  prolapsus  of  the  uterus  is  one  directed  to 
prevent  its  occurence.  In  order  to  prevent  prolapsus,  the  pehac 
floor  and  other  supports  must  be  kept  intact  and  the  uterus 
prevented  from  becoming  too  heavy. 

The  first  is  accomplished  by  preventing  laceration  and 


202  DISEASES   OF   WOMEN. 

injuries  during  childbirth.  Correct  any  bony  displacement 
as  soon  as  it  occurs,  this  preventing  an  impairment  of  the  nutri- 
tion of  the  pelvic  floor.  Avoid  use  of  warm  water  douches,  or 
in  fact  avoid  frequent  douching  of  any  description.  Take  plenty 
of  exercise  with  deep  breathing;  respiration  affecting  to  a  marked 
extent  the  pelvic  circulation.  Avoid  lifting  heavy  weights  or 
straining  the  abdominal  muscles,  especially  if  the  patient  is  not 
very  strong.  The  carrying  around  of  a  large  overgrown  baby  has 
broken  down  the  health  of  many  a  mother.  Avoid  wearing  heavy 
skirts  supported  by  bands  encircling  the  waist.  Avoid  tight 
clothes,  they  interfere  with  deep  respiration,  mechanically  ob- 
struct the  blood  flow,  and  cause  weakening  of  muscles  of  both 
the  back  and  abdomen.  Have  the  patient  attend  to  the  calls 
of  nature;  this  will  prevent  displacements  which  would  other- 
wise tend  to  occur.  The  straining  at  stool  in  a  constipated  con- 
dition of  the  bowels,  forces  the  uterus  to  a  lower  level,  and  if  the 
constipation  exists  for  any  length  of  time  the  uterus  will  pro- 
lapse. Care  should  be  taken  that  the  patient  does  not  walk  too 
much,  or  stand  on  her  feet  too  soon  after  delivery,  this  inter- 
fering with  involution  of  the  uterus  and  its  appendages. 

The  object  to  be  attained  in  the  treatment  of  a  prolapsus 
after  it  has  occurred  is,  first  to  replace  it,  and  second  to  keep 
IT  IN  position.  Sometimes  palliative  treatments  are  indicated 
when  it  is  impossible  to  replace  or  keep  the  uterus  in  place  after 
it  is  once  corrected. 

REPLACEMENT.     Generally,  little  difficulty  is  experienced 
in  replacing  a  prolapsed  uterus    unless  there  are  obstructions 
such  as  adhesions,  tumors  or  inflammatory    conditions  which 
hinder. 

The  contra-indications  to,  or  conditions  which  make  re- 
placement impossible  or   difficult,  are,  inflammatory  conditions 


AFFECTIONS    OF   THE    UTERUS.  203 

of  the  vagina,  uterus  or  its  appendages,  pelvic  peritonitis  and 
cellulitis,  adhesions  and  pelvic  growths.  If  adhesions  exist, 
and  this  can  be  ascertained  if  there  is  limitation  of  motion  in  a 
certain  direction  or  by  feeling  the  adhesive  bands,  care  should  be 
used,  since  a  hemorrhage  followed  by  inflammation  will  result, 
if  they  are  forcibly  broken  up. 

In  replacing  any  of  the  various  forms  of  uterine  displace- 
ment, have  the  patient  assume  a  position  so  that  the  force  of 
GRAVITY  will  help  in  the  reduction.  In  backward  displacements 
the  best  position  for  their  correction  is  the  semi-knee  chest  which 
is  obtained  by  placing  the  patient  on  the  left  side,  then  raising 
the  hips  to  an  angle  of  45  degrees  or  more.  The  hips  can  be  held 
by  the  operator's  knee  or  by  other  support,  such  as  a  pillow.  This 
position  permits  of  local  vaginal  work,  the  use  of  two  hands  and 
force  of  gravity.  In  cases  of  prolapsus,  since  there  is  also  re- 
troversion, it  is  advisable  to  place  the  patient  in  the  semi-knee- 
chest  position;  the  uterus  then  having  a  tendency  to  spontaneous 
reduction,  since  this  causes  the  pelvic  and  abdominal  viscera  to 
gravitate  toward  the  diaphragm,  this  relieving  the  pressure  on 
the  uterus.  A  hard  unyielding  table  is  best;  the  knees  sinking 
in,  hindering  the  operation  if  a  soft  yielding  bed  is  used;  the  ob- 
ject being  to  elevate  the  hips,  and  depress  the  chest  as  much  as 
possible. 

Use  gentle  manipulation  over  the  abdomen  for  some  five  or 
ten  minutes  if  the  pelvis  is  much  congested  or  inflamed,  before 
attempting  to  reduce  the  displacement,  by  which  the  viscera  are 
pulled  out  of  the  true  pelvis  and  the  space  anterior  to  the  uterus. 
This  allows  the  blood,  on  account  of  the  changed  position,  to 
DRAIN  OUT  of  the  uterus;  it  always  being  full  of  blood  when  in  a 
prolapsed  condition.  While  in  this  position,  the  index  finger  or 
both  index  and  middle  fingers,  are  introduced  as  far  as  the  va- 


204     "  DISEASES    OF    WOMEN. 

ginal  junction.  By  separating  the  two  vaginal  walls,  air  enters 
the  vaginal  canal  and  by  means  of  a  slight  pressure  on  the  pos- 
terior part  of  the  uterus,  and  backward  traction  on  the  cervix,  it 
will  assume  its  normal  position,  unless  held  by  adhesions  or  caught 
behind  the  promontory  of  the  sacrum.  No  violent  or  sudden 
force  should  be  exerted,  but  a  steady  pressure  by  which  it  is 
GRADUALLY  pushed  iuto  place.  When  two  fingers  are  used  make 
pressure  with  the  middle  finger  in  the  posterior  fornix  upward 
and  forward,  and  with  the  index  finger  exert  backward  traction 
on  the  cervix.  In  this  way  the  uterus  if  it  has  retained  its  tone, 
is  pried  into  normal  position.  If  the  uterus  is  soft  and  flexible 
so  that  it  bends  instead  of  turns,  pressure  with  the  internal  finger 
should  be  made  high  up  in  the  posterior  fornix.  With  the  ex- 
ternal hand  make  deep  pressure  over  the  abdomen,  finally  getting 
the  hand  back  of  the  uterus  and  the  fingers  of  the  two  hands 
approximated.  This  is  accomplished  best  by  beginning  the  ex- 
ternal   PRESSURE     HIGH,    that   is    OU    a    LEVEL    with    the    SACRAL 

PROMONTORY.  After  the  fingers  are  approximated,  lift  the  uterus 
upward  and  forward,  thus  carrying  it  into  normal  position.  This 
can  only  be  done  in  subjects  that  are  comparatively  free  from 
pelvic  inflammation  and  are  not  too  obese. 

In  the  above  methods  it  is  not  advisable  to  balloon  the  va- 
gina before  replacement;  since  by  so  doing  the  uterus  may  be 
forced  to  the  hollow  of  the  sacrum,  that  is  in  extreme  retrover- 
sion with  anteflexion;  it  accommodating  itself  to  the  shape  of 
the  anterior  surface  of  the  sacrum,  from  which  position  it  is  hard 
to  remove.  Many  an  error  has  been  made  in  not  observing 
the  above,  since  the  physician  thought  that  he  had  replaced  the 
organ   when  he  really  had  exaggerated  its  abnormality. 

To  clear  up  the  diagnosis  and  ascertain  whether  you  have 
really  replaced  the  organ,  examine  the  patient  in  the  latero-prone 


AFFECTIONS  OF  THE  UTERUS.  205 

position  a  short  while  after  the  attempted  replacement.  It  is  a 
good  practice  after  it  is  replaced  to  let  the  patient  lie  on  the  side 
or  in  the  ventral  position  for  some  time  until  the  ligaments  con- 
tract to  hold  it  in  position.  The  best  time  to  correct  this  form  of 
displacement,  as  well  as  any  retro-displacement,  is  just  before 
retiring.  If  it  is  replaced  at  such  a  time  and  the  patient  remains 
in  the  ventral  or  latero-prone  position  over  night,  the  uterus  will 
become  accustomed  to  the  change  and  remain  in  the  normal  posi- 
tion for  a  longer  length  of  time. 

Again,  if  the  patient  will  assume  the  genu-pectoral  position 
every  night  just  prior  to  retiring  it  will  help  to  relieve  the  con- 
gestion, lessen  the  pain  and  assist  in  the  reduction  of  the  dis- 
placement. In  ordinary  office  practice  it  is  useless  to  push  the 
uterus  upward  by  means  of  the  end  of  the  finger  unless  the  parts 
are  prepared  to  hold  it,  since  as  soon  as  the  patient  stands  erect 
it  drops  down  into  a  position  as  bad  as  it  was  formerly.  Treat- 
ments, as  are  ordinarily  given  while  patient  is  in  dorsal  position, 
are  worse  than  useless;  they  even  doing  harm  in  some  cases  by 
constantly  irritating  the  parts. 

After  reposition  of  the  organ,  it  should  be  raised  as  high  up 
as  possible  out  of  the  pelvis.  This  is  accomplished  by  intro- 
ducing the  right  index  finger  into  the  anterior  fornix,  then  by  ap- 
proximating the  internal  and  external  hand,  the  uterus  can  be 
caught  between  the  two  and  lifted  quite  high  in  the  pelvis.  Gentle 
y  massage  of  the  uterus  and  ligaments  is  beneficial  while  in  this 
position.  Brandt  claims  to  have  cured  from  70  per  cent,  to  80 
per  cent,  of  all  cases,  in  from  two  to  six  weeks  by  a  system  of 
massage  of  the  uterus.  The  principle  of  it  consists  of  grasping 
the  uterus,  and  while  the  cervix  is  steadied  and  held  with  the 
internal  hand,  the  fundus  and  body  are  thoroughly  massaged  and 
kneaded  with  the    external  hand.     This  is  repeated  as  often  as 


206  DISEASES    OF    WOMEN. 

the  patient   can  stand  it.     The  treatment  is  good  in  chronic  ad- 
hesions of  the  peritoneum  surrounding  the  uterus. 

Another  method  of    replacement  is  by    means    of  the  wdre 
uterine  repositor  invented  by  Dr.  Still.     (See  Fig.  65).      It  con- 


FiG  t)3. — The  wire  uterine  repositor. 

sists  of  a  wire,  bent  in  such  a  manner  that  it  will  encircle  the  cer- 
vix, attached  to  a  handle  which  is  almost  at  right  angles  to  the 
larger  end  or  part  introduced  into  the  vagina.  It  is  introduced 
like  a  speculum,  and  by  inserting  the  right  index  finger,  the  cer- 
vix can  be  located  and  the  loop  of  the  instrument  adjusted  around 
it.  After  it  is  in  position,  turn  the  patient  on  the  right  side, 
facing  the  operator,  and  gently  pull  toward  you.  The  "Old 
Doctor"  says,  make  the  umbilicus  the  objective  point,  that  is, 
pull  toward  it.  While  doing  this  the  air  will  enter  the  vagina 
between  the  two  strands  of  wire  which  form  the  handle,  they 
being  slight!}^  separated.  On  account  of  the  angle  formed  by 
the  handle  and  the  loop,  the  handle  corresponds  in  direction  to 
and  is  parallel  with,  the  utenne  axis.  By  gently  pulling  the  in- 
strument toward  you,  the  uterus  sinks  farther  down  into  the 
loop,  and  on  account  of  this  not  only  prolapsus,  but  flexions  and 
versions  can  be  straightened.  In  its  introduction,  remember 
the  direction  of  the  vaginal  canal,  othermse  you  may  find  it  diffi- 
cult to  introduce  or  you  may  injure  the  anterior  vaginal  wall. 
After  the  uterus  has  been  lifted  up,  hold  it  there  for  a  short  time 
vmtil  the  venous  drainage  is  well  established,  then  remove  instru- 
ment in  the   reverse   manner  of  introduction.     In  withdrawing 


AFFECTIONS    OF   THE    UTERUS. 


207 


the  instrument  be  careful  to  first  free  it  from  the  cervix.     To 
make  sure  that  the  cervix  is  entirely  out  of  the  loop,  it  is  best  to 


Fig.  66  — Showing  manner  of  introduction.    Note  the   direi'tion  of  loop  iuul  Iiandle. 

introduce  the  finger,  which  can  be  used  as  a  guide  in  detach- 
ing the  instrument,  and  in  ascertaining  whether  or  not  the  cer- 
vix is  entirely  removed  from  the  loop.  If  the  loop  still  encircles 
the  cervix  at  the  time  of  the  attempted  removal,  the  cervix  will 


208 


DISEASES    OF    WOMEN. 


be  pulled  forward  and  the  uterus  thereby  displaced.     This  in- 
strument IS  TO  BE  RECOMMENDED   ESPECIALLY  in  the  treatment 


Fig.  67. — Sliowing  adjustment  and  morements  in   replacing  prolapsus  with  wire 
repositor.    Tlie  dotted  lines  show  direction  handle  tildes  and  effect  on  uterus. 

of  prolapsus,  since   there  is  very  little  danger  of  injuring  any  of 
the  parts,  the  instrument  being  perfectly  smooth. 


AFFECTIONS  OF  THE  UTERUS.  209 

The  sound  is  used  by  some  in  replacing  a  prolapsus,  but  I 
think  it  should  be  avoided  if  possible,  all  other  methods  being 
employed  before  resorting  to  its  use.  The  uterus  can  be  replaced 
by  using  the  sound,  but  I  believe  injuries,  producing  conditions 
even  worse  than  the  prolapsus,  have  followed  its  use,  such  as 
puncturing  the  walls  or  bruising  the  endometrium.  Reed  says, 
"The  old  practice  of  introducing  a  curved  uterine  sound  and 
turning  it  around  in  the  uterine  cavity,  thus  forcing  the  uterus 
into  position,  has  been  denounced  by  intelligent  gynecologists 
and  abandoned  by  conservative  practitioners."  The  use  of  the 
sound  is  permissible  in  partial  inversion  of  the  uterus  after  child- 
birth, provided  a  large  one  is  used.  In  prolapsus,  if  used  at  all, 
the  sound  should  be  the  largest  that  can  be  introduced.  In 
fact  a  sound  smaller  than  little  finger  should  not  be  intro- 
duced into  the  uterus  on  the  account  of  the  likelihood  of  punctur- 
ing the  wall.  A  sound  of  the  above  mentioned  size,  is  not  likely 
to  injure  or  perforate  the  weakened  uterine  wall. 

The  second  indication  in  the  treatment  of  prolapsus  is  to 
keep  the  uterus  in  position  after  it  is  replaced.  This  can  be  done 
in  one  of  two  ways.  First,  by  decreasing  the  weight  of  the 
uterus;  and  second,  by  strengthening  the  supports;  the  causes 
of  the  condition  being,  increased  weight  of  or  pressure  on  the 
uterus,  or  a  weakening  of  the  supports  viz.,  the  pelvic  floor. 

If  the  uterus  is  too  heavy  and  pushes  the  floor  downward, 
the  weight  is  due  to  a  growth  on  it  or  an  increase  of  intra-abdom- 
inal pressure  or  a  congestion,  it  is  too  full  of  blood.  This  congestion 
can  be  relieved  by  removing  obstructions  to  the  venous  drainage. 

This  is  accomplished  in  part  by  correcting  a  prolapsed  dia- 
phragm. In  this  condition  the  lower  ribs  are  involved,  drawing 
the  diaphragm  down  with  them.  This  causes  obstruction  to 
the  vena  cava  at  the  point  of  passage  through  it,  and  the  blood 

14 


210  DISEASES    OF    WOMEN. 

is  retained  in  the  pelvic  organs.  Lift  up  the  intestines  that  have 
been  wedged  and  packed  in  the  pelvis;  this  condition  interferes 
with  the  return  circulation.  Work  over  the  iliac  veins  and  vena 
cava  to  remove  any  obstruction  at  those  points  to  the  free  venous 
drainage  and  to  restore  tone  to  the  walls  of  the  veins;  correct  any 
lesions  that  are  found  which  affect  the  vaso-motor  supply  to  the 
uterus.  Frequently  a  lesion  is  found  at  the  sacrum,  or  there  is  a 
twisted  pelvis  or  slipped  vertebra,  which  interferes  with  the  vaso- 
motor nerves,  shutting  off  a  part  of  the  nerve  force,  thus  causing 
a  relaxation  of  the  vessels  supplied  by  them;  the  most  common 
and  important  lesion  is  the  lumbar  subluxation  by  which  the 
uterine  vaso-motor  centers  are  disturbed. 

Tight  clothing,  especially  constricting  bands,  should  be 
forbidden,  as  they  interfere  with  the  return  flow  of  blood:  the 
weight  of  the  clothes  should  be  supported  from  the  shoulders  by 
some  kind  of  skirt  supporter  or  suspenders.  The  patient  should 
be  on  her  feet  as  little  as  possible  especially  at  the  menstrual 
period,  since  the  uterus  is  more  congested,  hence  heavier  at  that 
time  than  at  any  other.  Any  occupation  involving  being  on  the 
feet,  reaching  upward  or  lifting  weights  should  be  given  up,  at 
least  for  a  while.  As  mentioned  before,  the  best  time  to  correct 
this  form  of  displacement  is  in  the  evening,  for  the  treatment  can 
then  be  followed  by  rest.  This  permits  of  a  better  circulation 
through  the  uterus,  from  which  the  ligaments  strengthen  and 
contract  and  the  uterus  becomes  accustomed  to  its  new  posi- 
tion. 

Attempts  have  been  made  to  lighten  an  enlarged  uterus, 
due  to  hypertrophy  of  the  cervix,  by  amputating  the  cervix. 
This  is  a  method  which  should  not  be  resorted  to  since  it  is  pro- 
ductive of  so  little  good,  and  in  a  great  many  cases  of  so  much 
harm.     It  is  treating  the  result  of  the  disease,  not  the  cause. 


AFFECTIONS  OF  THE  UTERUS.  211 

THE  SUPPORTS  of  the  uterus  can  be  strengthened  in  several 
ways.  The  osteopathic  method  is  to  locate  the  lesion  that  in- 
terferes with  the  nutrient  supply  to  the  structures  composing  the 
pelvic  floor.  All  nerves  must  be  free  from  pressure  or  else 
their  function  is  deranged.  This  pressure  usually  occurs  at  the 
foramina  at  which  they  make  their  exit.  Slips  of  the  vertebrae, 
however  small,  will  bring  pressure  on  these  nerves;  either  directly 
by  the  bone  itself,  or  indirectly  bv  muscular  contraction.  This  shuts 
off  a  part  of  the  nerve  force,  depriving  the  muscles  of  their  proper 
nerve  energy,  hence  loss  of  tone  must  follow. 

A  DISPLACED  SACRUM  is  really  one  of  the  most  important  of 
bony  lesions,  interfering  with  the  nerve  supply  of  the  pelvic  floor. 
The  form  of  the  displacement  that  is  most  frequently  found,  is  a 
tilting  or  rotation  by  which  the  upper  part  is  thrown  forward 
and  the  lower  part  backward ;  or  else  a  downward  displacement  in 
which  it  is  wedged  between  the  innominata;  also  the  sacrum 
may  be  rotated  backward  until  it  is  almost  vertical.  The  coccyx 
being  movable,  is  drawn  under  or  forward  by  the  muscles  attached 
to  it.  The  innominate  bones  are  partly  dislocated  on  account  of 
the  disturbance  of  their  articulation  with  the  sacrum,  and  the 
equilibrium  of  the  pelvis  affected. 

In  general  the  abnormality .  is  usually  found  in  the  bony 
framework,  since  without  a  perfect  adjustment  of  these  bones, 
the  supports  of  the  uterus  can  not  be  permanently  strengthened. 
Remember  that  each  case  is  different;  only  a  general  rule  can  be 
given.  When  these  displacements  are  corrected,  nutrition  to 
the  pelvic  floor  will  be  restored;  when  this  is  accomplished  the 
uterus  will  be,  in  a  great  many  cases,  gradually  drawn  back  into 
its  normal  place  without  the  aid  of  a  local  treatment. 

In  addition  to  the  correction  of  the  lesions  as  mentioned, 
■CERTAIN  EXERCISES  are  of  value  in  strengthening  the  pelvic  floor, 


212  DISEASES    OF   WOMEN. 

Separation  and  approximation  of  the  knees  against  resistance  are 
very  good.  The  forcible  adduction  is  accompanied  by  prolonged 
and  forcible  contraction  of  the  levator  ani  muscle,  especially 
when  the  patient  at  the  same  time  raises  the  hips.  As  a  result 
the  lumen  of  the  vagina  diminishes  in  size,  the  uterus  is  forced 
upward  to  a  certain  degree  and  later  on,  after  the  exercise  has 
been  pursued  for  quite  awhile,  the  uterus  is  maintained  in  a  better 
position.  Another  exercise  called  the  "restraining  movement" 
is  of  great  value  in  strengthening  the  pelvic  floor.  It  consists 
of  forcible  contraction  of  the  sphincters  and  levator  ani  muscles, 
as  in  cases  of  threatened  defecation.  These  exercises  develop 
the  muscles  that  are  used.  The  muscles  of  the  pelvic  floor  form 
the  main  supports  of  the  uterus;  hence  the  condition  of  these 
muscles  determines  the  condition  of  the  floor  and  upon  it  depends 
the  position  of  the  uterus. 

Artificial  perineal  supports  have  been  used  in  connection 
with  abdominal  supports.  By  the  application  of  pads  suspended 
from  the  waist,  firm  pressure  is  brought  to  bear  on  the  weak 
points  of  the  pelvic  floor.  This  theory  will  seem  plausible  at 
first,  but  after  a  second  thought  it  will  be  seen  that  it  is  wrong. 
As  soon  as  nature  realizes  that  a  part  is  supported  artificially, 
ATROPHY  of  the  natural  supports  will  result,  since  they  would  no 
longer  be  of  use.  Instead  of  increasing  the  strength  of  the  natural 
supports,  these  artificial  means  both  weaken  them  and  prevent 
their  development,  and  when  the  practice  is  once  begun,  it  will 
be  necessary  to  keep  it  up,  for  the  supports  of  the  uterus  grow 
weaker  the  longer  their  function  is  subserved. 

ASTRINGENTS  applied  to  the  vaginal  walls  have  been  used 
for  the  purpose  of  strengthening  them  and  thus  support  the 
uterus  for  a  time.  Tannin,  alum  and  persulfate  of  iron  have  been 
used,  but  I  fail  to  see  how  any  curative  or  permanent  value  re- 


AFPECTONS  OF  THE  UTERUS.  213 

suits  from  their  application.  It  is  applying  the  treatment  to  the 
wrong  end  of  the  disorder;  the  symptom  instead  of  the  cause.  In 
order  that  the  supports  be  strengthened,  and  this  will  have  to  be 
accomplished  if  you  realize  a  cure,  they  must  be  nourished  and 
strengthened  by  a  natural  process,  or  in  other  words,  there  must 
be  a  good  blood  supply.     It  is  admitted  by  all  that  there  is  no 

NOURISHMENT  IN  THE  ASTRINGENTS  MENTIONED,   and  they  do    UO 

good  except  that  they  produce  a  temporary  contraction  of  the 
mucous  membrane  of  the  vagina,  which  soon  disappears,  leaving  the 
walls  flabbier  than  they  were  before  the  astringents  were  used. 

PESSAKIES.  The  pessary,  (from  a  word  meaning  an  oval 
shaped  stone,)  is  an  instrument  placed  in  the  vagina  to  hold  the 
uterus  in  position.  There  are  a  great  many  different  kinds,  both 
as  to  shape  and  material  from  which  they  are  made.  They  are 
constructed  so  that  they  will  encircle  the  cervix  and  by  resting 
on  the  vaginal  wall,  principally  the  posterior,  act  as  an  artificial 
support.  The  same  remarks  might  be  applied  to  the  use  of  pessa- 
ries that  were  made  in  reference  to  the  use  of  perineal  supports, 
viz.,  they  weaken  the  natural  supports,  and  once  their  use  is  be- 
gun, the  patient  can  not  very  well  get  along  without  them.  A 
great  many  cases  come  to  me  for  treatment  that  have  been  wear- 
ing a  pessary  for  years.  The  pessary  is  a  foreign  body.  It  will 
be  a  source  of  irritation  if  placed  in  the  genital  tract.  This  irri- 
tation disturbs  the  blood  supply,  producing  congestion  and  in 
some  cases  inflammation.  In  cases  in  which  they  have  been 
worn  for  some  time,  the  patient  invariably  has  metritis  or  va- 
ginitis with  a  leucorrheal  discharge,  which  accompanies  a 
congested  condition  of  the  genital  tract.  The  question  is  often 
asked  me,  "should  a  pessary  be  removed  when  a  patient  comes 
to  an  osteopathic  physician  for  treatment?"  This  is  a  question 
that  confronts  us  all  and  one  that  is  hard  in  some  cases,  to  answer. 


214  DISEASES    OF    WOMEN. 

Suppose  a  woman  had  worn  one  for  years — what  would  be  the 
condition  of  the  vagina  and  uterus?  They  would  certainly  be 
very  weak  and  flabby,  especially  the  vaginal  walls.  In  such  a 
case  I  WOULD  advise  the  removal  of  the  pessary  if  the  patient 
CAN  possibly  do  WITHOUT  IT.  Its  presence  hinders  the  strength- 
ening of  the  parts,  impairs  nutrition  and  disturbs  circulation  and 
should  be  removed  at  once  if  a  cure  is  to  be  hoped  for.  However, 
if  the  patient  on  removal  of  the  pessary,  has  a  great  deal  of  pain, 
locally  or  reflexly,  or  by  removal,  it  produces  great  weakness  or 
nervousness,  it  should  not  be  left  off  too  abruptly;  but  gradually 
get  the  patient  to  do  without  it  by  having  her  leave  it  off  as  long 
at  a  time  as  she  can. 

To  the  osteopath,  the  pessary  is  an  unnecessary  article  and 
its  use  not  indicated.  Even  the  medical  authorities  are  begin- 
ning to  discard  it.  Reed,  in  speaking  of  their  use,  says,  "so  much 
manifest  injury  comes  from  their  employment  that  it  has  been 
very  largely  abandoned."  Byford  says,  "Pessaries  are  as  a  rule 
more  harmful  than  beneficial.  The  only  indication  for  them  is 
to  support  the  uterus  so  as  to  prevent  traction  upon  the  tender 
sacro-uterine  ligaments  or  peritoneal  adhesions  and  a  tampon 
answers  the  purposes  better."  In  cases  in  which  there  is  senile 
atrophy  of  the  vaginal  walls,  there  is  prolapsus,  but  as  a  rule  it 
does  not  produce  as  many  and  bad  symptoms  as  it  does  in  young 
subjects.  I  relieve  most  of  these  cases  without  resorting  to  the 
use  of  the  pessary,  and  if  its  use  is  indicated  in  any  kind  of  case; 
it  certainly  would  be  in  this  kind.  I  have  treated  patients  sent 
to  the  A.  T.  Still  Infirmary  who  had  worn  a  pessary  so  long  with- 
out removing  it,  that  it  had  buried  itself  in  the  vaginal  walls  and 
was  partly  destroyed  by  the  discharges.  If  one  is  worn  at  all 
it  should  not  be  for  more  than  a  day  or  so  without  removal. 

The  STEM  pessary  has  been  worn  for  prolapsus.     It  is  so 


AFFECTIONS  OF  THE  UTERUS.  215 

arranged  that  a  stem  is  introduced  directly  into  the  cavity  of  the 
uterus,  and  is  retained  in  position  by  various  bands  which  encircle 
the  waist.  This  kind  of  pessary  is  certainly  a  barbarous  way  of 
exciting  endometritis  and  I  am  glad  to  say,  this  form  is  fast  be- 
coming obsolete. 

Vaginal  tampons  are  sometimes  used  by  the  osteopaths  in 
cases  in  which  the  uterus  can  not  be  kept  in  place  and  the  dis- 
placement CAUSES  EXTREME  PAIN.  The  common  tampon  is  made 
by  taking  a  piece  of  absorbent  cotton,  or  better,  lamb's  wool,  some 
four  inches  wide  by  eight  inches  long,  covered  with  glycerine  and 
then  folded  into  a  wad  approximately  two  inches  long  by  one,  to 
one  and  one-half  inches,  in  diameter.  A  string  is  tied  around  it 
by  which  it  may  be  removed.  After  lubricating  the  tampon  and 
fingers  with  glycerine  it  is  introduced  without  the  use  of  the  specu- 
lum while  the  patient  is  in  the  Sims  or  knee-chest  position.  While 
the  patient  is  in  this  position,  the  shoulders  being  lower  than  the 
hips,  the  intestines  drop  downward  and  the  vagina  is  ballooned. 
This  permits  of  easy  introduction  of  the  tampon  and  at  the  same 
time  the  uterus  is  as  high  as  it  can  be  placed ;  thus  a  tampon  prop- 
erly placed  will  hold  the  uterus  well  up  in  position.  One  is  usually 
sufficient,  although  two  may  be  used.  If  it  is  a  case  of  retro- 
flexion it  is  placed  in  the  posterior  fornix.  In  retroversion,  two  are 
used ;  one  is  placed  in  the  anterior  fornix,  thereby  forcing  the  cer- 
vix back,  or  rather  preventing  it  from  going  forward,  and  the  other, 
in  the  posterior  fornix,  high  up  against  the  body.  If  the  uterus 
has  retained  its  tone,  retroversion  can  be  corrected  so  long  as 
the  tampon  is  worn,  which  should  not  be  longer  than  36  hours 
without  change. 

Some  advise  replacing  the  uterus  after,  instead  of  before, 
the  introduction  of  the  tampon.  By  temporarily  supporting  the 
uterus  in  this  way  the  irritation  is  lessened  and  the  uterus  held 


216  DISEASES    OF    WOMEN. 

in  position,  thus  allowing  the  blood  to  drain  out.  In  using  the 
ordinary  type  of  tampon,  the  one  described  above,  if  large  enough 
to  distend  the  orifice  of  the  vagina,  and  usually  it  is,  considerable 
DAMAGE  MAY  RESULT.  The  repeated  downward  pressure  or  traction 
on  the  vaginal  walls  has  a  tendency  to  pull  the  uterus  to  a  lower 
level    in  the    pelvis,   instead  of  supporting  or  pushing  it  higher. 

The  CHAIN  TAMPON  is  the  best  form.  It  consists  of  several 
little  tampons  tied  together  at  an  interval  of  about  four  inches. 
On  account  of  their  size  and  number  they  can  be  so  placed  that 
pressure  is  exerted  on  the  cervix  or  body,  or  in  fact  the  uterus 
can  really  be  supported  when  they  are  properly  placed  and  pack- 
ed. In  prolapsus  several  can  be  packed  behind  the  uterus,  one 
in  front  of  the  cervix  and  one  under  the  end  of  the  cervix. 

Another  type,  recommended  by  some,  consists  of  a  long 
narrow  roll  of  lamb's  wool  or  cotton.  With  such  a  tampon  it  is 
comparatively  easj^  to  pack  the  fornices.  It  is  removed  by  at- 
taching a  string  to  it  and  leaving  the  end  protrude  from  the  va- 
gina. Although  they  are  rarely  resorted  to,  yet  I  think  they  are 
beneficial  in  some  forms  of  prolapsus. 

OPERATIVE  means  are  most  frequently  resorted  to  at  the 
present  time  by  surgeons,  to  cure  prolapsus  of  the  uterus.  One 
method  is  to  resect  a  portion  of  the  vaginal  walls,  stitch  the  edges 
together  and  thus  produce  a  narrowing  of  the  vaginal  canal.  It 
also  forms  scar  tissue  in  the  walls  which  increases  their  rigidity. 
This  operation  generally  fails  because  it  does  not  restore  the  nor- 
mal angle  between  the  vagina  and  uterus,  and  any  pressure 
forcing  the  uterus  downward  will  re-dilate  the  vaginal  canal. 
The  operation  is  called  colporraphy  or  elytrorraphy. 

Another  method  is  to  stitch  the  uterus  to  the  abdominal 
wall;  the   operation  being  called  abdominal   fixation  or  hyster- 
orraphy.     The  dangers,  if  impregnation  occurs,  are  abortion, 


AFFECTIONS  OF  THE  UTERUS.  217 

HYPEREMESis  and  dystocia,  all  of  which  result  from  the  adhesion 
uniting  the  uterus  to  the  abdominal  wall,  preventing  the  uterus 
from  assuming  a  normal  position  or  size  after  impregnation.  Also 
the  dangers  attending  any  laparotomy  accompany  ventro-fixa- 
tion.  Other  operations  have  been  resorted  to,  among  which  is 
Alexander's  operation  for  shortening  the  round  ligaments. 
These  operations  should,  ordinarily,  not  be  resorted  to,  on  account 
of  the  risk,  the  uncertainty  of  a  cure  or  even  of  helping  the  pa- 
tient, until  a  fair  trial  has  been  given  the  case  by  osteopathic 
methods. 

According  to  some  European  statistics,  regarding  opera- 
tions for  prolapsus,  over  thirty  per  cent,  of  all  cases  are  complete 
failures,  however,  the  American  statistics  do  not  show  such  a 
high  per  cent,  of  failures.  The  osteopath  has  a  reputation  of 
preventing  operations,  this  being  one  way  by  which  an  im- 
provement has  been  made  upon  surgery. 

ANTEVERSION  OF  THE  UTERUS.  Versions  and  flexions 
are  determined  and  named  from  the  position  of  the  fundus  and 
its  relation  to  the  cervix.  When  the  fundus  is  forward  it  is  known 
as  an  anteflexion  or  anteversion;  when  backward,  retroversion  or 
retroflexion.  By  version  is  meant  a  rotation  of  the  uterus  on 
its  transverse  axis.  This  axis  passes  through  the  uterus  at  the 
junction  of  the  cervix  and  body.  A  flexion  is  a  bending  of  the 
uterus  on  its  long  axis,  which  corresponds  to  the  long  diameter  of 
the  uterus.  Anteversion  of  the  uterus  is  a  condition  in  which 
the  uterus  is  turned  forward  to  a  pathological  degree. 

The  uterus  normally  is  in  a  position  of  anteversion  and  slight 
anteflexion,  but  if  this  is  increased  so  that  if  the  angle  formed  be- 
tween the  vaginal  and  uterine  axes  is  less  than  a  right  angle 
ACCOMPANIED  BY  BLADDER  SYMPTOMS,  it  is  regarded  as  pathologi- 
cal.    If  the  uterus  is  in  a  normal  position,  its  axis  corresponds  to 


218 


DISEASES    OF    WOMEN. 


a  line  drawn  from  a  point  michvay  between  the  symphysis    pubis 
and  the  umbilicus,  to  the  hollow  of  the  sacrum,  this  line  varying 


KiG.  t)S. — Anteverslon  of  the  uterus. 


a  trifle  in  distended  or  collapsed  condition  of  the  bladder.  Since 
the  line  of  demarcation  between  the  normal  and  abnormal  can  not 
be  definitely  located  or  fixed,  experience  has  to  be  relied  upon.     In 


AFFECTIONS    OF   THE    UTERUS.  219 

GENERAL  terms,  it  might  be  stated  that  when  the  long  axis  of  the 
uterus  is  found  lying  across  the  pelvis,  the  fundus  behind  the 
symphysis  and  resting  on  the  bladder,  and  the  cervix  very  high 
and  pointing  to  the  hollow  of  the  sacrum,  pathological  antever- 
sion  of  the  uterus  exists. 

An  anteversion  presupposes  an  increase  in  size,  such  as 
hj'perplasia,  chronic  metritis  and  subinvolution,  especially  of  the 
fundus  of  the  uterus;  while  anteflexion  indicates  atrophy,  weak- 
ening and  malnutrition  of  the  entire  uterus,  but  especially  at  the 
point  of  bending,  on  which  account  a  flexion  is  regarded  as  a 
WORSE  displacement  than  a  version,  and  anteversion  in  par- 
ticular. In  a  version  the  tonicity  of  the  uterus  is  retained 
to  a  certain  degree,  this  permitting  of  a  turning  instead  of  a  bend- 
ing, such  as  we  find  in  flexion  . 

In  version  the  direction  of  the  cervix  is  always  changed  as 
well  as  the  direction  of  the  uterine  axis.  In  flexion  the  cervix  is 
seldom  displaced,  but  the  uterine  axis  is  bent  on  itself.  Ante- 
flexion is  often  associated  with  anteversion,  the  mobility  at  the 
angle  of  flexion  usually  being  increased. 

CAUSES.  Any  disorder  that  increases  the  weight  of 
the  uterus  ^\ith  retention  of  tone,  unless  there  is  at  first  a  back- 
ward displacement,  will  produce  anteversion.  The  most  common 
cause  foimd  is  inflammation  of  the  uterus.  Since  an  inflam- 
mation is  always  preceded  by  a  congestion,  we  must  find  the 
cause  of  the  congestion  in  order  to  treat  it  intelligently.  This 
congestion  may  be  produced,  as  mentioned  under  the  head  of 
prolapsus,  by  any  obstruction  to  the  venous  return  or  vaso-motor 
disturbances  produced  by  lesions  affecting  the  vasomotor  cen- 
ters of  the  uterus.  In  subinvolution  there  is  congestion  of  the 
uterus,  this  sometimes  producing  an  anteversion,  it  depending 
on  the  position  and  degree  of  subinvolution;  but  usually  a  retro- 


220  DISEASES    OF    WOMEN. 

version  or  prolapsus  is  the  result  on  account  of  its  position,  the 
uterus  being  back,  as  a  result  of  the  relaxed  condition  of  the  lig- 
aments following  childbirth.  Pressure  on  the  uterus  from 
above,  produces  a  disturbance  in  the  circulation,  increases  its 
weight;  this  resulting  in  anteversion  in  some  cases.  In  case  there 
is  a  weakened  condition  of  the  uterine  supports,  the  uterus, 
especially  the  fundus  or  heavy  end  will  sink  to  a  lower  level,  if 
the  uterus  is  in  normal  or  nearly  normal  position.  The  writer 
recently  treated  a  case  of  this  kind.  Multipara,  patient  anemic 
and  very  weak.  The  uterus  was  very  large  and  if  the  patient  was 
on  her  feet  for  any  length  of  time,  the  fundus  would  fall  farther 
forward  and  downward  and  would  cause  considerable  distress 
until  replaced.  The  anterior  vaginal  wall  was  very  weak,  re- 
sulting in  a  cystocele,  this  contributing  to  a  general  weakness 
and  helping  to  cause  the  displacement. 

Neoplasms  on  the  posterior  wall  of  the  uterus,  force  it  down 
into  a  position  of  anteversion.  Bladder  disturbances  of  all  vari- 
eties complicate  such  conditions.  In  such  cases  the  uterus  can 
be  pushed  up  but  immediately  descends  to  its  former  position 
when  pressure  is  removed. 

During  the  early  months  of  pregnancy,  the  uterus  is  pushed 
forward  and  downward  on  the  bladder;  however,  anteflexion  is 
more  common  than  anteversion.  Contraction  of  the  utero-sac- 
ral  ligaments  pulls  the  cervix  and  lower  part  of  the  body  higher 
up  into  the  hollow  of  the  sacrum;  and  if  there  is  a  shortening  or 
contraction  of  the  round  ligaments  at  the  same  time,  anteversion 
will  occur.  Adhesions  between  the  anterior  wall  and  bladder 
will  pull  the  fundus  lower,  since  all  scar  tissue  contracts  during 
its  formation.  The  causes  of  these  adhesions  can  be  traced  back 
to  a  metritis  or  inflammation  of  the  peritoneum  which  as  men- 
tioned above,  are  the  principal  causes. 


AFFECTIONS    OF   THE    UTERUS.  221 

SYMPTOMS.  There  are  no  symptoms  characteristic 
OF  ANTEVERSiON,  PER  SE,  they  being  associated  with  the  compli- 
cations produced  by  the  displacement.  As  in  all  displacements, 
there  is  a  sense  of  weight,  fullness,  and  of  distress  in  the  pelvic 
cavity.  In  most  cases  there  is  a  settling  or  sinking  of  the 
UTERUS,  this  explaining  many  of  the  symptoms  attributed  to 
anteversion.  Pain  is  present  over  the  uterus  and  is  reflected  to 
the  symphysis  and  lower  lumbar  region.  The  bladder  is  irri- 
tated by  the  pressure  exerted  on  it  by  the  uterus  and  frequent 
micturition  is  the  result.  This  pressure,  if  exerted  for  any  length 
of  time,  and  especially  if  there  is  an  inflamed  condition  of  the 
uterus,  may  set  up  a  cystitis  or  inflammation  of  the  bladder.  In 
some  cases  this  is  so  marked  that  mucous  plugs  lodge  in  the  urethra 
and  when  expelled,  give  rise  to  an  intense  griping  pain  and 
followed  by  marked  sediment  in  the  urine,  with  strong  odor  and 
deposit  of  pus  in  variable  quantities. 

Pressure  of  the  cervix  on  the  posterior  wall  of  the  vagina  is 
frequently  the  cause  of  a  leucorrheal  discharge,  and  the  pressure 
against  the  rectum  results  in  disturbances  such  as  tenesmus  or 
a  painful,  irritable  state,  which  is  exaggerated  during  defecation. 
Further,  we  may  have  a  train  of  general  symptoms  which  gen- 
erally follows  any  long  standing  displacement  or  irritation  of  the 
pelvic  organs;  to  wit:  derangement  of  the  digestive  tract 

AND  THE  NERVOUS  SYSTEM. 

DIAGNOSIS.  The  diagnosis  is  made  by  locating  both 
ENDS  of  the  uterus,  there  being  little  trouble  in  accomplishing 
this.  On  local  examination,  the  cervix  can  be  felt  high  up  toward 
the  hollow  of  the  sacrum.  The  Sims  position  is  to  be  preferred, 
since  in  this  position,  examination  can  be  made  higher  up  the 
vagina  than  in  the  dorsal  position,  it  being  very  difficult  or  im- 
possible to  reach  the  cervix  with  the  examining  finger  while  the 


222  DISEASES    OF    WOMEN. 

patient  is  in  the  dorsal  position.  The  anterior  fornix  will  be 
found  to  be  shallow  and  very  much  widened,  the  posterior  fornix 
is  decreased  or  entirely  obliterated,  this  depending  on  the  degree 
of  displacement.  A  hard  body  can  be  plainly  felt  through  the 
anterior  fornix;  this  is  ascertained,  by  a  conjoined  manipulation, 
to  be  the  body  and  fundus  of  the  uterus.  The  fundus  cannot 
be  palpated  through  the  abdomen  unless  pushed  up  by  the  in- 
ternal finger,  it  lying  behind  the  symphysis  pubis  and  on  the  blad- 
der. The  bladder  should  be  empty  when  the  examination  is 
made,  since  this  will  assist  in  the  conjoined  manipulation.  The 
uterus  will  be  found  enlarged  and  of  firm  texture.  The  mobility 
should  be  tested  and  the  presence  or  absence  of  adhesions  ascer- 
tained. The  POSITION  of  the  cervix,  it  being  high  and  pointing 
up  and  back;  the  absence  of  a  marked  curve  of  the  anterior 
wall  of  the  uterus,  as  is  determined  by  palpation  through  the 
anterior  fornix,  diagnose  anteversion  from  anteflexion.  If  a 
tumor  exists  on  the  anterior  wall  the  diagnosis  can  be  made  by 
locating  the  fundus  by  the  bimanual  method,  it  being  in  about  its 
normal  position,  or  if  displaced  it  will  be  a  retro-deviation.  In 
cases  in  which  there  is  much  inflammation  which  prevents  a  com- 
plete vaginal  examination,  the  rectal  method  enables  us  to  ascer- 
tain that  the  uterus  is  at  least  not  in  retroversion  and  lying  back 
against  the  rectum.  An  anteversion  may  be  mistaken  for  a 
congenital  retroflexion  if  only  the  position  of  the  cervix  is 
relied  on  in  making  the  diagnosis;  but  a  rectal  or  bimanual  ex- 
amination will  clear  up  the  diagnosis. 

TREATMENT.  The  treatment  indicated  in  most  cases,  is 
one  directed  to  relieve  the  congestion  or  inflammation  of  the 
uterus,  since  these  conditions  are  found  in  the  majority  of  cases, 
and  are  the  most  important  of  all  indications.  Sometimes  these 
conditions  are  causes,  but  usuallv  are  secondarv  or  the  result  of 


AFFECTIONS  OF    THE    UTERUS.  223 

the  displacement.  If  the  uterus  is  turned  forward,  it  certainly 
will  TWIST  and  put  a  tension  on  the  broad  ligaments;  the  blood 
vessels  being  located  between  the  two  layers,  this  tension  then 
forms  an  obstruction  to  the  circulation.  In  order  to  relieve 
this  t\\'isting,  the  uterus  must  be  replaced. 

Replacement  is  generally  accomplished  by  placing  the  pa- 
tient in  the  dorsal  position,  sometimes  elevating  the  hips  by 
placing  the  knee  or  a  pillow  under  the  patient;  introducing  the 
index  finger,  or  better,  two  fingers,  into  the  vagina  and  locating 
the  anterior  fornix.  By  exerting  pressure  through  this,  and 
pulling  downward  and  forward  on  the  cervix,  the  funtlus  can  be 
pushed  or  pried  out  of  the  pelvis  high  enough  to  be  grasped  b}-  the 
external  hand;  thus  having  it  between  the  two  hands  it  can  be 
readily  pushed  into  place.  This  is  readily  accomplished  in  a  thin 
subject,  but  in  an  obese  patient  you  will  have  to  rely  on  the  va- 
ginal treatment  alone,  The  uterus  can  not  be  felt  through  the 
anterior  abdominal  wall,  in  patients  that  are  very  obese,  since 
with  difficulty  can  it  be  palpated  in  this  manner  in  ordinary  cases 
in  which  the  abdominal  wall  is  only  slightly  thickened. 

In  the  unmarried  in  which  class  of  cases  a  local  treatment 
should  be  avoided  as  long  as  possible,  upward  manipulation  ap- 
plied to  the  abdomen  at  a  point  just  above  the  symphysis  pubis, 
with  the  hips  elevated,  \\i\\  often  correct  the  displacement  with- 
out a  local  treatment;  but  this  applies  better  to  an  anteflexion 
than  to  an  ante  version. 

The  wire  uterine  repositor  invented  by  Dr.  Still  can  be  used 
to  good  advrntage  in  cases  of  anteversion.  By  the  additional 
reach  obtained  by  its  use,  the  cervix  can  be  readily  manipulated 
while  the  patient  is  in  the  dorsal  position.  By  depressing  the 
handle  slightly  downward  and  forward,  the  loop  having  been 
placed  around  the  cer\ax.  the  uterus  can  be  rotated  into  position. 
(See  Fig.  69.) 


224 


DISEASES    OF   WOMEN. 


A  sound  has  been  used  for  replacing  an  anteverted  uterus, 
but  I  think  its  use  is  not  indicated  in  any  case,on  account  it  being 


3:' 


Fic.  (:9. — The  use  of  the  wire  uterine  repositor  itt anteverelon.  1,  introduction;  2,  ad- 
justing; 3,  first  movement;  4,  direction  of  handle  when  operation  is  completed. 

hard  to  introduce  one  without  injury,  and  since  the  uterus  can 
be  readily  replaced  without  it. 

Just  as  soon  as  it  is  replaced,  the  congestion  begins  to  dis- 
appear and  the  bladder  symptoms  leave,  and  the   patient  feels  a 


AFFECTIONS  OF  THE  UTERUS.  225 

great  deal  better  in  every  respect.  If  the  patient  is  kept  quiet 
for  awhile  until  the  ligaments  contract,  it  will  probably  remain  in 
place;  but,  if  the  patient  gets  up  immediately  it  will,  in  most 
instances,  drop  forward  again  with  a  renewal  of  the  former  symp- 
toms.    On  account  of  this  I  am  often  asked  the  question — How 

OFTEN  WOULD  YOU  GIVE  A  LOCAL  TREATMENT?      This  depends  Upon 

the  amount  of  pain  and  nervousness.  If  the  displacement  is 
causing  severe  pain,  replace  it;  if  it  falls  forward  in  a  few  hours, 
replace  it  again,  but  this  time  put  the  patient  to  bed,  or  at  least 
advise  her  to  keep  quiet  until  the  supports  are  strengthened. 
Ordinarily  I  give  as  few  local  treatments  as  I  can  possibly  get 
along  with,  perhaps  one  every  week  or  ten  days,  this  depending 
on  the  individual  case. 

In  addition  to  replacing  the  uterus  the  blood  may  be  emptied 
out  of  it  by  work  along  the  veins  leading  from  it.  This  is  similar 
to  the  treatment  given  under  prolapsus.  In  addition,  correct  the 
bony  displacements  found ;  they  are  the  predisposing  causes.  They 
weaken  the  supports,  impair  the  nutrition  and  interfere  with  the 
circulation;  then  the  exciting  cause,  such  as  a  fall  or  heavy  lift^ 
the  more  readily  results  in  a  displacement. 

The  prognosis,  in  a  case  of  anteversion,  depends  upon  the 
causes  found  and  the  condition  and  general  health  of  the  patient. 
If  the  patient  is  debilitated  and  very  weak,  it  will  take  some  time 
to  strengthen  the  part  so  that  the  uterus  will  be  held  in  position 
because  the  displacement  is  the  result  of  a  weakening  of  the  sup- 
ports and  is  incomplete  and  gradual.  If  the  patient  is  strong  and 
there  is  no  loss  of  tonicity  of  the  tissues,  the  prognosis  is  good, 
since  a  cure  is  generally  effected  by  a  replacement  of  the 
organ.  Versions  are  more  readily  replaced,  and  more 
quickly  cured,  than  flexions. 

ANTEFLEXION  OF  THE  UTERUS.     The  canal  of  the  nor- 

15 


226 


DISEASES    OF   WOMEN. 


mal  uterus  is  straight  or  slightly  curved  ^\ith  the  concavity    for- 
ward and  downward.     When  it  forms  a  more  decided  curve  or 


Fig.  70. — The  wire  uterine  repositor  in  position  in  normal  case. 

angle,  accompanied  by  dysmenorrhea  and  vesical  irritation;  or  if 
there  is  an  interference  with  the  drainage  of  the  uterine  cavity  or 


AFFECTIONS    OF   THE    UTERUS. 


227 


with  impregnation,  it  is  called  a  pathological  axteflexiox. 
Dudley  says,  "Anteflexion  is  pathological  if  the  mobility  at  the 
angle  of  flexure  is  increased  or  diminished  or  absent."  The 
movements  of  the  uterus  are    commensurate  with  thevar\dng 


P^ia.  71. — Cervical  jiuteflexlon  of  the  uteruK. 

■quantity  of  urine  in  the  bladder.  If  flexure  does  not  disap- 
pear when  the  bladder  fills,  but  remains  constant  under  all  con- 
ditions, the  rigidity  makes  the  flexure  pathological.  This  con- 
dition is  more  frequently  found  in  the  nulliparous  than  in  the 


228 


DISEASES    OF    WOMEN. 


parous,  FIRST,  because  the  weight  of  the  intestines  and  the  ab- 
dominal pressure  exerting  a  force  on  the  posterior  wall,  tend  to 
exaggerate  the  normal  condition  of  slight  anteflexion;  second,  in 


Fig.  72. — Corporeal  anteflexion  of  the  uterus. 

pregnancy  the  uterus  is  carried  backward  and  upward,  so  stretch- 
ing the  round  ligaments   that  it  prevents  them  pulling  the  uterus 


AFFECTIONS    OF    THE    UTERUS. 


229 


back  into  the  position  which  had  existed  before  pregnancy;  third, 
on  account  of  the  condition  of  the  uterus  during  involution  and 
the  vascular  condition  of  the  different  ligaments,  the  uterus  re- 


FiG.  73.— Cervico-corporeal  anteflexion. 


mains  in  a  higher  position  in  the  pelvis  than  it  did  formerly. 

The  usual  seat  of  flexion  is  at  the  point  of  junction  of  the 
cervix  and  the  body,  or  it  may  be  at  the  upper  portion  of  the  cer- 


230 


DISEASES    OF   WOMEN. 


vix.  The  different  classifications  are  based  on  the  point  of  flex- 
ion ;  such  as  a  corporeal,  in  which  the  bend  is  in  the  body,  throw- 
ing the  fundus  forward  and  downward,   the  cervix  remaining  in 


Fig.  71. — Very  marked  anteflexion.     (Irreducible). 

normal  position;  cervical,  in  which  the  cervix  is  bent  forward;  and 
corporo-cervical,  in  which  both  are  thrown  forward,  that  is  there 
is  a  bend  in  both  body  and  cervix. 


AFFECTIONS   OF  THE    UTERUS.  231 

The  cervical  form  may  be  mistaken,  on  vaginal  examination^ 
for  retroversion,  since  the  cervix  is  in  line  with  the  vaginal  axis; 
the  DIAGNOSIS  must  be  made  by  the  bimanual  or  rectal  examina- 
tion. Sometimes  there  is  a  congenital  form  of  anteflexion  in 
which  the  cervix  is  small,  elongated  and  the  os  so  very  much  re- 
duced in  size,  that  it  is  called  the  pin  hole  os.  In  a  majority  of 
all  cases  both  the  external  and  internal  ora  are  small. 

These  displacements  vary  in  degree  from  a  slight  bending  of 
the  uterine  canal  to  that  of  a  complete  semicircle,  the  fundus 
and  cervix  almost  touching  each  other.  The  writer  recalls  hav- 
ing several  cases  in  which  the  uterus  was  bent  into  the  shape  of  an 
inverted  "U,"  the  fundus  pushing  back  the  anterior  vaginal 
wall. 

The  anterior  wall  at  the  point  of  flexion  undergoes  a 
change  in  which  there  is  a  weakening  of  its  muscle  fibers.  The 
posterior  wall  becomes  thin  on  account  of  the  stretching  to  which 
it  is  subjected.  When  this  condition  exists  for  any  great  length  of 
time,  these  structural  changes  tend  to  become  permanent  and  the 
displacement  is  regarded  as  incurable  and  is  called  an  Irreducible 
flexion.  There  is  much  loss  of  symmetry,  and  generally  hard- 
ening of  the  concave  side.  This  condition  of  irreducible  flex- 
ion, is  found  to  be  most  frequent  in  the  congenital  type,  due 
to  some  accident  or  cause  which  resulted  in  an  error  in  develop- 
ment. When  the  fundus  is  very  heavy  or  large,  the  displace- 
ment may  become  immovable;  there  usually  being  adhesions 
which  hold  it  in  that  position.  In  most  cases,  especially  if  there 
is  no  pelvic  inflammation,  the  uterus  is  movable  and  the  bend  in 
the  uterus  can  be  straightened  by  pressure  against  the  fundus  or 
by  means  of  a  sound.  The  degrees  of  flexion  vary,  and  the  symp- 
toms vary,  but  with  the  amount  of  pelvic  inflammation  and  de- 
gree of  development  rather  than  the  amount  of  flexion. 


232  DISEASES    OF    WOMEN. 

CAUSES.     The   fundus  is   supported   by  the   Fallopian 

TUBES,  ROUND  LIGAMENTS,  BROAD  LIGAMENTS,  and  the  body  of  the 

uterus.  The  last  mentioned  support  is  the  most  important.  On 
examination  of  a  cadaver  the  broad  Hgaments  are  found  to  be 
flaccid,  and  allow  quite  a  flexion  of  the  uterus  to  take  place  be- 
fore they  are  made  tense.  If  they  were  tense  cords  they  would 
support  the  uterus,  but  such  not  being  the  case,  they  only  act  as 
stays  placed  on  each  side,  preventing  too  much  lateral  motion. 

In  the  case  of  an  anteflexion  of  the  acquired  type,  in  which 
the  fundus  has  dropped  forward  and  downward,  there  must  be 
some  trouble  with  its  supports,  that  is,  with  the  lower  part  of 
THE  BODY  of  the  uterus.  This  trouble  is  a  softening  of  the  uterine 
walls  from  chronic  metritis.  This  weakening  is  the  result  of 
some  disturbance  of  the  nutrition  of  the  anterior  wall  of  the  uterus. 
In  an  inflamed  condition  of  the  uterine  walls,  they  are  at  first  firm 
but  afterwards  become  soft  and  weak,  and  the  weight  to  be  sup- 
ported by  them  is  greater  on  account  of  the  passive  congestion. 
Every  strain  of  the  body  and  every  weight  lifted  forces  the  uterus 
farther  forward,  when  once  it  gets  a  start  in  that  direction.  The  walls 
having  lost  their  elasticity  on  account  of  lack  of  nutrition,  are 
bent  more  and  more  until  a  decided  flexion  exists.  The  farther 
forward  it  is  forced,  the  more  congested  the  uterus  will  be  on 
account  of  the  relation  of  the  blood  vessels  to  the  broad  ligaments. 
But  to  get  at  the  primary  cause  of  the  congestion  we  must  ex- 
amine the  venous  return  and  the  condition  of  the  vaso-motor 
nerves  which  are  distributed  to  the  pelvic  organs. 

A  BONY  or  MUSCULAR  lesiou  affecting  the  vaso-motor  nerves, 
the  usual  effect  being  that  of  inhibition,  serves  to  dilate  the  ves- 
sels innervated  by  them,  thus  producing  engorgement  of  the 
organ.  There  may  be  a  prolapsed  condition  of  the  bowels  from 
various  causes,  this  obstructing  the  venous  blood  on  its  way  to  the 


AFFECTIOXS    OF   THE    UTERUS.  233 

heart.  Any  lesion  or  obstruction  that  produces  venous  conges- 
tion or  chronic  inflammation  of  the  uterus,  especially  in  the 
nulliparous  woman,  will  usually  produce  a  flexion  of  the  uterus 
on  account  of  the  weakening  and  softening  of  the  uterine  walls. 

A  change  in  the  tissues  composing  the  uterus  takes  place; 
this  change  is  one  of  atrophy  or  weakening  of  them.  This,  as  a 
result,  lessens  resistance  and  the  uterus  yields  to  the  extraneous 
pressure.  When  the  uterus  is  in  a  normal  position  and  be- 
comes congested  from  the  causes  mentioned  above,  and  as  it  bends 
forward  of  its  own  weight,  the  intra-abdominal  and  pelvic  pres- 
sure, acting  on  the  posterior  wall,  wdll  gradually  exaggerate  the 
condition. 

The  CHARACTER  OF  THE  DRESS  has  a  great  deal  to  do  with  the 
degree  of  flexion,  or  in  many,  with  the  causation  of  it.  If  too 
tight,  it  tends  to  congest  the  uterus,  thus  making  the  displace- 
ment worse.  A  lesion  at  the  sacro-iliac  synchondrosis  predis- 
poses to  a  flexion  since  it  affects  the  nutrition  of  the  uterus.  This 
effect  is  partly  the  result  of  an  interference  with  the  innervation 
of  the  sacro-uterine  ligaments  and  partly  the  result  of  direct 
pressure  on  or  disturbance  of,  the  anterior  sacral  nerves.  Other 
lesions,  such  as  a  subluxated  innominate  or  displaced  lumbar  ver- 
tebra, are  frequently  found.  These  weaken  the  uterine  walls, 
sometimes  shutting  off  the  nutrition  of  a  part,  and  if  this  be  the 
anterior  wall,  anteflexion  will  result. 

Every  muscle  fiber  has  a  center  in  the  spinal  cord 
WHICH  controls  ITS  TONE.  This  center  is  in  the  anterior 
horns  of  the  GREY  matter.  The  activity  of  this  center  deter- 
mines the  nutrition  and  tone  of  the  muscle  fibers.  In  the  case  of 
the  uterine  muscle  fibers,  the  center  is  in  the  lumbar  enlargement 
of  the  spinal  cord  and  when  these  cells  which  comprise  the  center 
are  mal-nourished   the  effect  is  manifest  in  an  atrophied,  soft, 


234 


DISEASES   OF   WOMEN. 


uterus.  It  makes  little  difference  how  good  the  circulation  through 
the  uterus  is.  the  blood  does  not  tone  it  up  unless  this  center  is 
IN  GOOD    WORKING  ORDER.     If  a  mau's  stomach  is  diseased,  it 


Vui.  75 — Anteflexion  of  uterus  from  artliesion  beliind. 

makes  little  difference  how  much  food  is  ingested,  for  un- 
less  ASSIMILATION   TAKES    PLACE    HE    WILL    GRADUALLY    STARVE, 

Lesions  of  the  vertebrae  affect  the  blood  supply  to  these  cells 
from  which  the  nerves  controlling  the  uterine  muscle  fibers  get 
their  impulses. 


AFFECnONS    OF    THE    UTERUS.  235 

Inflammatory  changes  behind  the  uterus,  by  producing 
shortening  of  the  sacro-uterine  ligaments,  often  result  in  ante- 
flexion. If  you  will  remember  the  attachment  of  the  ligaments, 
you  can  the  better  understand  how  a  shortening  of  the  same  will 
draw  the  lower  part  of  the  body  upward.  This  shortening  of  the 
ligaments  is  most  commonly  the  result  of  inflammation;  the  in- 
flammation was  preceded  by  a  congestion,  this  congestion  re- 
sulting from  several  things,  such  as  localized  poison  as  is  found 
in  gonorrhea,  causing  a  partial  paralysis  of  the  vaso-motor 
nerves,  or  from  the  various  bony  lesions  which  affect  the  pelvis. 
These  thickened  bands  or  ligaments  can  be  felt  on  local  examina- 
tion and  care  must  be  exercised  in  treating  them,  for  a  forcible 
breaking  up  of  them  will  often  result  in  an  acute  peritonitis. 

A  FIBROID  TUMOR  on  the  fundus  or  posterior  wall  will  either 
bend  the  uterus  forward  by  the  increased  weight  or  force  it  for- 
ward by  the  pressure  exerted  behind  the  growing  tumor.  This 
cause  is  almost  entirely  confined  to  nullipara.  In  the  beginning 
of  pregnancy,  that  is,  up  to  the  third  month,  the  uterus  ante- 
flexes,  and  forms  from  its  anterior  position  and  shape,  one  of  the 
best  of  the  early  signs  of  pregnancy,  the  uterus  being  found  to 
resemble  in  shape  an  inverted  jug. 

Unequal  involution  of  the  uterus  during  the  puerperium 
is  a  cause  of  the  acquired  form  of  anteflexion.  The  placental 
site,  being  on  the  posterior  wall,  prevents  it  from  involuting  so 
rapidly  as  the  anterior  wall. 

Unequal  development  is  the  cause  of  the  congenital 
form.  Since  the  uterus  lies  dormant  up  to  the  age  of  puberty, 
and  at  that  time  undergoes  a  wonderful  developmental  change, 
any  interference  with  its  nutrition,  such  as  directing  the  nerve 
force  by  overwork  through  another  channel,  will  result  in  a  non-, 
or  imperfectly  developed  organ.     This  causes  many  cases  of  the 


236  DISEASES    OF    WOMEN. 

so-called  infantile  uterus,  which  can  be  traced  back  to  some  ac- 
cident at  puberty.  In  such  cases  is  found  the  worst  type  of  ante- 
flexion. The  menstrual  pains  are  more  severe  is  this  form  of  ante- 
flexion than  in  any  other  form.  The  fornices  are  shallow,  the  os 
small,  the  vagina  long  and  the  uterus  high.  The  cervix  in  most 
cases  is  somewhat  elongated  and  situated  in  the  long  axis  of  the 
vagina;  such  conditions  are  most  frequent  and  best  marked  in 
the  obese.  If  pregnancy  ever  does  take  place  the  labor  is  very 
hard. 

In  other  cases  there  is  a  congenital  predisposition  to 
flexion;  that  is,  the  girl  is  born  with  a  weakened  condition  of  the 
uterus  at  the  point  of  junction  of  the  body  and  cervix;  then  the 
posture,  mode  of  dress  and  occupation,  all  of  which  produce 
pressure  on  the  upper  and  back  part  of  the  uterus,  force  it  down 
in  anteflexion. 

In  still  other  cases  the  sacro-uterine  ligaments  remain  short 
and  hold  the  uterus  high  in  the  pelvis  as  it  is  during  infancy. 

THE  SYMPTOMS.  The  symptoms  of  anteflexion  of  the 
uterus  depend  upon  its  impingement  on  itself  and  neighboring 
structures;  narrowing  or  stenosis  of  the  uterine  canal;  amount  of 
inflammation  in  and  around  the  uterine  walls,  and  various  re- 
flex disturbances  affecting  organs  that  are  weakened  by  le- 
sions. The  organs  and  structures  impinged  on  are  the  bladder  and 
the  anterior  vaginal  walls,  the  pressure,  exerted  like  that  in  ante- 
version,  producing  frequent  micturition  and  sometimes  a  conges- 
tion or  inflammation  of  the  mucous  lining  of  the  bladder,  result- 
ing if  severe  enough  in  some  cases  in  cystitis.  The  frequent  mic- 
turition is  due  not  so  much  to  the  mechanical  pressure  exerted  on 
the  bladder,  as  to  the  inflammation  of  the  uterus.  The  greater 
the  degree  of  inflammation  the  more  frequent  the  micturition. 
Another  point  in  favor  of  this  theory  is  that  frequent  micturition 


AFFECTIONS  OF  THE  UTERUS.  237 

occurs  in  many  cases  of  retro-displacements  when  metritis  exists 
partly  as  a  result  of  the  inflammation  extending  to  the  bladder 
and  partly  from  traction  on  the  bladder. 

Pain  occurs  when  the  bladder  is  distended  and  sometimes  the 
sensation  of  distress  follows  immediately  after  evacuation  of  the 
bladder.  This  peculiar  griping  pain  is  due  to  an  effort  on  the  part 
of  the  bladder  to  expel  an  imaginary  foreign  body.  The  irrita- 
tion is  the  result  of  the  inflamed  uterus  pressing  on  the  bladder. 
Impulses  arising  from  this  pressure  reach  the  micturition  center, 
thus  resulting  in  an  attempted  evacuation;  the  center  mistaking 
the  impulses  for  the  normal  impulses  which  are  formed  when  the 
bladder  is  distended.  Sometimes  the  contraction  of  the  utero- 
sacral  ligaments  draws  the  lower  part  of  the  body  upward  and 
backward,  thus  putting  on  a  tension  the  vesico-vaginal  walls, 
which  condition  can  be  ascertained  by  local  vaginal  examination. 

Impingement  on  the  walls  of  the  uterus  at  the  point  of  flexion 
affects  circulation,  nutrition  and  secretion,  and  finally  results  in 
atrophy  of  the  wall.  This  wall  becomes  weaker  and  thinner,  as 
regards  normal  uterine  tissue,  but  there  is  a  gradual  increase  in 
deposit  of  fibrous  material  the  longer  the  pressure  exists,  and 
finally  reaches  such  a  degenerative  stage  that  the  displacement 
becomes  very  hard  to  correct. 

The  flexion  also  narrows  or  causes  a  complete  stenosis  of 
the  uterine  and  cervical  canals.  The  secretions  will  then  be  re- 
tained, -which  undergoing  changes  cause  irritation  of  the  en- 
dometrium. Abortion  follows  such  conditions  if  the  constric- 
tion is  not  complete  enough  to  prevent  impregnation. 

Endometritis  frequently  complicates  with  its  attending  pains 
and  reflexes.  The  collapse  or  obstruction  of  the  uterine  canal 
will  prevent  or  interfere  with  the  expulsion  of  the  menstrual  dis- 
charge, giving  rise  to  dysmenorrhea  or  painful  menstruation.     In 


238  DISEASES    OF    WOMEN. 

this  kind  of  dysmenorrhea  the  pain  ceases  as  soon  as  the  flow 
starts,  but  it  is  rare  to  get  a  typical  case,  for  endometritis  is  pres- 
ent in  most  of  the  cases.  It  also  takes  more  force,  that  is, 
HARDER  UTERINE  Contractions  to  expel  the  menstrual  fluid  up 
and  around  a  curve,  thus  the  pain.  In  anteflexion,  the  fundus  is 
low  and  the  blood  accumulates  in  the  cavity  at  this  point,  which 
is  lower  than  the  curved  portion.  If  endometritis  complicates 
the  flexion  the  pain  will  be  severe,  since  the  contraction  of  the 
muscle  involving  an  inflamed  area  will  certainly  be  productive  of 
pain  of  the  worst  type.  I  am  inclined  to  the  belief  that  in  most 
cases  of  dysmenorrhea,  the  inflammation  is  the  real  cause  of 
THE  pains.  In  other  cases  the  pain  is  due  to  strong  uterine  con- 
tractions. If  the  blood  is  prevented  from  escaping  it  will  coagu- 
late, and  in  order  to  force  the  coagula  through  a  narrow  canal  the 
uterus  has  to  go  into  labor,  and  the  uterine  contractions 
SIMULATE  LABOR  PAINS.  Inflammation  of  the  endometrium  and 
walls  permits  coagulation  of  the  retained  menstrual  flow. 

If  there  is  little  inflammation  the  pain  will  be  in  proportion 
to  the  amount  of  it  and  from  this  we  will  conclude  that  the  dys- 
menorrhea accompanying  anteflexion,  is  mostly  due  to  the  in- 
flammation and  only  is  partly  due  to  a  narrowing  of  the  canal. 
The  writer  has  seen  cases  in  which  upon  examination  with  the 
speculum  during  menstruation,  clots  were  forced  out   of  an 

APPARENTLY  VERY  SMALL  OS  UNACCOMPANIED  BY  PAIN,  there  being 

no  inflammation  of  the  uterus.  Also  other  patients  likewise  ex- 
amined, suffered  great  pain  on  the  expulsion  of  coagula  from  a 
patulous  OS.  If  the  patient  is  married  and  has  anteflexion, 
usually  there  is  sterility.  The  spermatozoa  are  either  unable  to 
gain  entrance  into  the  uterine  cavity  on  account  of  its  oblitera- 
tion from  flexion,  or  else  the  diseased  condition  prevents  them, 
after  impregnation  has  occurred,  from  becoming  attached  to  the 


AFFECTIONS   OF   THE    UTERUS.  239 

uterine  wall.  Since  the  leucorrheal  discharge  from  a  diseased 
uterus  usually  is  acid,  it  counteracts  the  alkaline  spermatozoa. 
If  patients  suffering  from  anteflexion  become  pregnant  there  is 
almost  sure  to  be  hyperemesis.  This  can  be  relieved  in  part  by 
straightening  the  curve,  which  is  best  done  by  a  local  digital 
treatment.  In  marked  types  of  anteflexion,  the  effort  necessary 
to  raise  the  uterus  out  of  the  pelvis  often  gives  rise  to  uterine  con- 
tractions SEVERE  ENOUGH  to  expel  the  contents  of  the  uterus,  this 
constituting  a  common  cause  of  abortion.  On  the  other  hand 
pregnancy  is  one  of  the  the  surest  cures  for  anteflexion  if  the  pa- 
tient carries  to  term.  Anteflexion,  if  chronic,  is  accompanied  by 
the  usual  reflexes,  such  as  backache,  headache,  or  in  some,  gastric 
disturbances  and  functional  heart  trouble.  These  reflexes  rather 
depend  upon  the  amount  of  inflammation  present,  than  upon  the 
kind  or  degree  of  the  flexion. 

DIAGNOSIS.  The  diagnosis  of  anteflexion  of  the  uterus  is 
made  by  a  vaginal  and  bimanual  examination.  As  the  finger 
passes  into  the  vagina  and  touches  the  cervix  nothing  abnormal, 
if  it  is  a  typical  case,  wiW  be  noticed;  the  direction  of  the  cervix 
not  usually  being  changed  in  an  anteflexion.  In  some  cases  the 
anterior  lip  will  be  elongated  or  rather,  the  posterior  lip  of  the  cer- 
vix will  be  shortened,  on  account  of  the  traction  exerted  on  the 
posterior  uterine  wall,  this  giving  the  anterior  lip  the  appearance 
of  being  elongated,  or  of  a  small  growth  upon  it.  As  the  finger 
sweeps  along  the  anterior  wall  of  the  uterus  at  a  point  just  above 
the  OS  internum,  a  protuberance  will  be  met  with,  which  is  the 
body  or  fundus  of  the  uterus  pressing  against  the  bladder  and 
the  anterior  vaginal  wall.  By  outlining  the  anterior  wall  of  the 
uterus  with  the  examining  finger  in  the  anterior  fornix  of  the 
vagina,  a  marked  conga vity,  curve  or  angle  can  be  outlined. 
When  this  curve  or  angle  of  flexion  is  discovered  and  there  is  no 


240  DISEASES    OF    WOMEN. 

tumor,  the  diagnosis  is  positive.  Keeping  the  finger  upon  the 
mass,  the  other  hand  should  be  placed  upon  the  abdomen  just 
above  the  symphysis  pubis  and  made  to  compress  the  abdominal 
wall  so  that  the  two  hands  will  be  approximated.  By  this  means 
the  shape,  size  and  sensitiveness  of  the  body  can  be  ascertained. 

To  differentiate  the  body  felt  in  the  anterior  fornix  from  a 
fibroid  tumor,  consider  the  form  of  menstrual  disturbance  and  by 
the  bimanual  method  outline  the  fundus,  which  would  be  posterior 
if  a  tumor  were  present.  Sometimes  the  use  of  a  sound  is  advo- 
cated. If  the  sound,  on  introduction,  meets  with  resistance  it  is 
diagnosed  as  a  flexion  if  the  other  symptoms  are  present;  but  if 
the  sound  meets  with  no  resistance  and  the  uterine  cavity  is  elonga- 
gated,  it  is  probably  a  fibroid  tumor.  There  is  always  danger  in 
the  use  of  a  sound  for  diagnostic  purposes,  since  one  is  very  likely 
to  injure  the  uterine  wall,  not  knowing  the  direction  of  the  canal. 

The  POSITION  of  the  cervix  will  diagnose  anteversion 
from  ANTEFLEXION  siuce  in  anteversion  it  is  changed  in  direction, 
while  in  anteflexion  it  usually  is  not.  In  case  it  is  changed,  it  is 
thrown  forward  rather  than  backward.  If  in  doubt  after  making 
the  bimanual  examination,  make  a  rectal  examination,  since  by 
this  it  can  be  ascertained  that  the  uterus  is  not  retro-deviated, 
for  nothing  but  the  cervix  can  be  felt  through  the  anterior  rectal 
wall.  On  vaginal  examination,  especially  in  congenital  cases,  cerv- 
ical anteflexion  may  be  mistaken  for  retroversion ;  but  the  diagnosis 
is  cleared  up  by  the  bimanual  method  and  by  feeling  the  angle  of 
flexion.  Quite  often  there  is  an  anteflexion  with  a  retroversion 
or  retroposition.  This  is  ascertained  by  finding  the  cervix  in 
line  with  the  vaginal  axis,  the  body  in  retroposition  and  by  feel- 
ing the  curve  or  angle  in  the  anterior  uterine  wall.  The  ante- 
fiexion,  if  primary,  becomes  an  irreducible  one  and  then  while  in 
this  state,  the  uterus  is  forced  backward  by  the  usual  causes. of 


AFFECTIONS    OF   THE    UTERUS. 


241 


retroversion.  The  uterus  remains  back  and  retains  its  curve, 
hence  the  apparently  paradoxical  condition.  The  symptoms  and 
treatment  of  this  condition  are  the  same  as  for  simple  retroversion, 
except  in  cases  of  obstructive  dysmenorrhea.  In  such  cases  the 
uterine  canal  ought  to  be  straightened  or  dilated. 

PROGNOSIS.  The  prognosis  of  an  anteflexion,  as  to  straight- 
ening the  canal,  is  unfavorable,  but  relief  can  be  promised  in 
most  cases.     The  ability  to  straighten  the  curve  depends  on  the 


Fi«.   76. — Retroversion  with  aiitefli'ction. 
(By ford) 

amount  of  fibrous  tissue  deposited  at  the  angle  of  flexion.     Since 

the  inflammation  and  weakening  of  the  wall  at  the  point  of  flexion 

is  the  real   cause  of  the  disturbances,  the  flexure  in  itself  need 

create  no  anxiety,  for  it  is  not  of  great  importance  except  that  it 

may  cause  sterility  on  account  of  obstruction  of  the  uterine  canal. 

TREATMENT.     The    points  indicated  for  the  treatment  of 

anteflexion   are   first,    reduction   of   the   inflammation;   second, 

strengthening  of  the  uterine  walls;  and  third,  opening  up  of  the 

uterine  canal  by  reducing  the. flexion.     It  must  be  borne  in  mind 
16        ■  " 


242  DISEASES    OF   WOMEN. 

that  flexions  are  unlike  versions  in  respect  to  the  rapidity  in  which 
they  are  formed.  Versions  may  occur  suddenly  from  a  fall  or 
violent  strain,  while  flexions  occur  gradually  from  a  weaken- 
ing of  the  uterine  walls  or  pressure  long  continued.  Therefore 
versions  are  susceptible  of  immediate  relief,  while  as  a  rule,  flex- 
ions are  not,  since  they  are  the  consequences  of  influences  long 
kept  up. 

The  reduction  of  the  metritis  accompanying  anteflexion  is 
accomplished  by  the  correction  of  the  causes  producing  it.  The 
BONY  lesions  found,  must  be  reduced  or  else  the  local  treatments 
will  do  little  if  any  good.  These  lesions  affect  nutrition  of  the 
walls,  and  in  order  to  cure  the  flexion  the  walls  must  be  strength- 
ened. These  lesions  also  affect  the  uterme  circulation, thus  to 
reduce  the  inflammatory  condition  the  vascular  supply  must  be 
made  normal,  which  is  done  in  part,  by  correcting  the  bony  le- 
sions found  especially  in  the  lumbar  region. 

The  uterine  walls  are  straightened  by  repeated  replacement 
of  the  organ.  The  pressure  of  a  flexion  increases  the  atrophy  and 
weakness  of  the  wall,  and  must  be  straightened  out  before  a  com- 
plete cure  can  be  attained. 

Keplacement  is  effected  by  placing  the  patient  in  the  dorsal 
position,  introducing  one  or  two  fingers  into  the  vagina,  and 
pressing  upward  on  the  anterior  fornix,  through  which  the  body 
and  fundus  can  be  felt.  After  it  has  been  forced  up  as  high  as 
possible  the  fundus  can  then  be  grasped  by  the  external  hand. 
When  this  is  done,  and  the  uterus  firmly  caught,  it  can  be  bent 
into  position  very  readily.  The  objection  to  this  is  the  diffi- 
culty in  obese  people,  of  being  able  to  feel  the  uterus  through  the 
abdominal  wall.  In  such  cases  the  physician  will  have  to  rely 
upon  the  pressure  exerted  by  the  vaginal  finger,  and  in  most 
xiases  it  can  be  replaced  in  this  way.     It  is  best  to  have  the  hips 


AFFECTIONS  OF  THE  UTERUS.  243 

elevated  while  replacing  the  organ,  and  after  the  displacement  is 
corrected  the  patient  should  rest  for  some  time  in  the  dorsal  posi- 
tion. 

The  OBSTACLES  to  replacement  are  adhesions,  inflammation 
of  and  arovmd  the  uterus  and  structural  changes  in  the  uterus, 
usually  most  common  at  the  point  of  flexion. 

Sometimes  anteflexion  can  be  corrected  by  external 
ABDOMINAL  MANIPULATION.  I  have  taken  cases  of  dysmenorrhea, 
dependent  upon  an  anteflexion,  and  by  elevating  the  hips  and 
workmg  deeply  over  the  abdomen  with  an  upward  motion,  I  have 
been  able  to  straighten  the  uterine  canal,  thereby  starting  the 
flow  and  relieving  the  pain.  1  make  it  a  practice  of  giving  this 
treatment  first,  in  cases  of  anteflexion  in  nullipara,  since  it  re- 
moves the  pressure  exerted  by  the  intestines  and  certainly  tends 
to  correct  the  displacement,  and  in  many  it  is  entirely  corrected 
in  this  way. 

If  it  is  impossible  to  replace  the  organ  by  these  means,  resort  is 
made  to  the  use  of  a  sound.  This  method  is  mentioned  more  for 
the  sake  of  completeness  than  as  an  important  therapeutical 
measure.  The  cases  in  which  the  use  of  a  sound  is  indicated  are 
very  rare.  The  patient  should  be  placed  in  the  Sims  position. 
After  warming,  lubricating  and  disinfecting  the  sound,  it  can  be 
introduced  in  the  manner  previously  described.  It  is  a  painful 
operation  and  should  be  done  as  slowly  and  gently  as  possible. 
Be  careful  to  first  diagnose  the  position  of  the  uterus  and  then  use 
no  force  in  the  uitroduction  of  the  sound.  Schultze  says,  "The 
uterus,  when  normally  flexible  and  movable,  slips  over  the  instru- 
ment if  the  latter  is  carefully  introduced,  even  though  the  direc- 
tion given  to  it  may  differ  very  materially  from  that  in  which  the 
uterus  itself  was  previously  lying."  But  if  the  uterus  is  in  any 
way  fixed,  the  sound  can  not  be  passed  as  Schultze  describes  un- 


244  DISEASES   OF   WOMEN. 

less  its  point  be  carried  forward  in  the  direction  of  the  cavity; 
and  even  after  the  shape  and  position  of  the  uterus  have  been  ex- 
actly ascertained,  it  is  often  very  difficult  to  bend  the  sound  into 
such  a  shape  that  it  can  be  introduced  into  the  cavity.  On  ac- 
account  of  the  inflamed  condition  of  the  endometrium,  any  force 
USED  will  INJURE  the  endometrium  and  bring  on  pain  and  in 
many  cases  hemorrhage.  Unless  the  sound  is  clean  it  may  carry 
disease  to  this  weakened  endometrium  and  set  up  a  more  severe 
endometritis.  After  the  sound  is  in  position  the  uterus  can  be 
moved  at  will  unless  adhesions  bind  it  down.  Be  careful  not  to 
use  much  force  since  you  have  a  greater  lever  power  than  you 
imagine.  Ordinarily  by  simply  bringing  the  handle  forward, 
that  is,  towards  the  patient's  limbs,  the  uterus  can  be  forced  into 
place.  After  this  is  done  it  should  be  carefully  withdrawn  and 
the  patient  left  either  in  the  latero-prone  or  dorsal  position  for 
some  time.  It  produces  quite  a  shock  to  the  nervous  system 
and  should  not  be  repeated  within  several  days,  even  if 
found  that  the  uterus  has  become  displaced  again.  Also  the 
sound  should  not  be  used  after  the  tenth  day  following  menstrua- 
tion if  it  can  be  otherwise  avoided,  since  it  is  apt  to  bring  on  the 
menses.  Frequently  a  leucorrheal  discharge  will  follow  the  use 
of  a  sound,  but  this  only  lasts  for  a  short  time  and  is  due  to  the 
disturbance  of  the  tender  endometrium  or  a  straightening  of  the 
uterine  canal,  thus  allowing  the  retained  secretions  to  escape. 

The  use  of  a  stem  pessary  has  been  resorted  to  by  some,  but  I 
think  their  use  is  productive  of  mo  re  harm  than  good.  This  pessary 
when  used  is  a  source  of  irritation  to  the  uterus,  increases  danger 
of  infection,  and  instead  of  doing  good,  very  frequently  leads  to  a 
more  serious  metritis. 

When  anteflexion  is  irreducible  and  dysmenorrhea  and 
sterility  exist  on  account  of  the  obstruction  to  the  uterine  canal, 


AFFECTIONS  OF  THE  UTERUS.  245 

surgeons  have  made  an  artificial  opening  by  various  operations, 
such  as  an  excision  of  the  posterior  lip,  lateral  incision,  amputa- 
tion of  the  entire  cervix,  etc.  The  writer  has  seen  many  cases  in 
which  a  longitudinal  incision  has  been  made  the  entire  extent  of 
the  vaginal  portion  of  the  cervix,  and  invariably  the  patient  was 
not  even  relieved  of  the  dysmenorrhea.  Amputation  of  the  cer- 
vix has  given  a  higher  per  cent,  of  relief  than  the  above  mention- 
ed operation,  although  some  cases  have  been  made  a  hundred 
times  worse  by  such  an  operation.  Operations  should  never  be 
resorted  to  until  it  is  evident,  after  careful  and  thorough  trial, 
that  the  case  can  not  otherwise  be  cured  or  relieved,  and  even 
then  they  are  experiments  in  most  cases. 

RETROFLEXION  OF  THE  UTERUS.  Retroflexion  of  the 
uterus  is  a  displacement  in  which  it  is  bent  backward  on  itself 
in  contra-distinction  to  anteflexion, m  which  it  is  bent  forward  on 
itself.  Retroflexion  is  preceded  in  most  cases  by  retroversion^ 
that  is,  THE  UTERUS  is  FIRST  TURNED  BACKWARD,  then  the  intra- 
abdominal and  pelvic  pressure  is  exerted  against  the  anterior 
wall,  thus  bending  it  further  backward.     (See  Fig.  77.) 

This  displacement  with  the  accompanying  complex  train  of 
symptoms  is  one  of  the  most  important  that  comes  to  the  gyne- 
cologist. Since  retroversion  invariably  precedes  it,  there  is  to  con- 
tend with,  the  double  displacement  with  all  the  symptoms  of  each. 
It  occurs  less  frequently  than  anteflexion;  first  on  account  of  the 
natural  anterior  obliquity  favoring  the  anteflexion;  and  second, 
the  retroflexion  is  more  thoroughly  guarded  against  by  the  liga- 
mentous supports ;  the  round  ligaments,  running  from  the  horns  of 
the  uterus  to  the  vulva,  tending  very  decidedly  to  prevent  a  back- 
ward bending.  They  not  only  do  this,  but  if  softening  of  the 
walls  from  inflammation  of  the  uterus  occurs,  they  would  natural- 
ly draw  it  forward;  yet,  if  the  softening  is  the  result  of  chronic 


246  DISEASES    OF    WOMEN. 

metritis,  the  uterus  descends  and  the  round  ligaments,  bemg  com- 
posed of  structure  similar  to  the  uterus,  soften  and  stretch. 

CAUSES.  As  in  anteflexion,  we  find  softening  of  the 
wall  from  metritis  a  very  common  cause.  The  indications  of  the 
chronic  metritis  are  general  pelvic  tenderness  and  adhesions 
which  limit  the  mobility  of  the  uterus.  These  adhesions  are 
often  threadlike  and  friable  while  in  the  worst  types  they  are  ex- 
tensive, thick  and  tough.  The  inflammation  extends  to  the 
round  ligaments  whose  function  it  is  to  hold  the  uterus  in  normal 
anteversion.  This  weakens  them,  and  by  their  relaxation,  the 
uterus  IS  bent  backward  by  a  very  slight  force  exerted  from  the 
front  or  above.  If  the  sacro-uterine  ligaments  are  relaxed  and 
the  cervix  is  allowed  to  go  forward,  which  condition  is  necessary  in 
backward  displacements,  retroversion  will  complicate  the  retro- 
flexion ,  and  this  is  the  condition  in  a  large  per  cent,  of  all  cases  of 
retroflexion.  Schultze  says  that  the  cause  of  ninety  per  cent,  of 
cases  is  "relaxation  of  the  sacro-uterine  ligaments  due  to 
constipation;  general  weakness  with  relaxation  of  all  the  pelvic 
cellular  tissues;  but  particularly  to  post  partum,  pathological 
conditions,  such  as  a  lacerated  cervix  and  vaginal  fornices,  getting 
up  too  soon,  etc."  This  metritis,  as  has  been  mentioned,  is  the 
result  of  a  disturbed  blood  supply.  Bony  lesions,  which  affect 
the  centers  that  control  the  blood  supply  of  the  uterus,  cause  a 
venous  stagnation,  on  account  of  which  the  blood  undergoes 
changes,  poisonous  materials  collect  which  result  in  an  attempt  on 
the  part  of  the  organism  to  rid  itself  of  this  poison,  which  attempt 
we  call  inflammation.  No  constant  particular  lesion  is  found;  but 
there  usually  exists  a  subluxation  at  the  sacrum,  innominata,  or 
of  the  lumbar  vertbrae.  The  vaso-motor  centers  for  the  internal 
genitalia,  according  to  Quain,  are  in  the  lumbar  spinal  cord.  The 
impulses  travel  over  the   lumbar  cerebro-spinal  nerves  or  white 


AFFECTIONS    OF    THE  UTERUS. 


247 


rami  to  the  ganglia,  thence  to  the  uterus  by  way  of  the  aortic  and 
hypogastric  plexuses  to  the  pelvic,  thence  to  the  uterine  plexus., 
A  curvature  in  the  lumbar  region  must  of  necessity,  affect  the.- 


Fig.  77.— Retroflexion  preceded  by  retroversion.    Tlie  common  form. 

circulation  of  blood  through  the  uterus,  unless  it  develops  so 
slowly  that  compensation  can  take  place. 

Again, these  lesions  affect  the  motor  nerve  supply  to  the 
muscle  fibers  composing  the  uterus.  A  muscle  fiber  to  be  nor- 
mal, must  have  a  certain  amount  of  nerve  force  traveling  to  it, 


248 


DISEASES    OF   WOMEN. 


giving  it  tone.  When  this  nerve  force  is  increased  in  amount,  the 
uterus  contracts  as  in  parturition  and  menstruation.  When 
this  nerve  force  is  lessened,  the  muscle  fibers  of  the  uterus  relax, 


Fig.   18  — Kxtrenie  retroflexion    with  softening  of  wall   at  point  of 
flexure.     (Irreducible). 


weaken  and  atrophy.     This  is  illustrated  best  in  the  cases  of 
atonic  paralysis. 

This  relaxation  of  the  tissues  of  the  uterus  is  the  important 
cause  of  flexion.     The  center  for  the  tone  of  the  muscles  of  the 


AFFECTIONS  OF  THE  UTERUS.  249 

Uterus  is  in  the  anterior  horns  of  the  grey  matter  of  the  lumbar 
spinal  cord.  The  above  mentioned  bony  lesions  affect  these  cen- 
ters by  interfering  with  their  nvitrition  and  by  affecting  the 
nerves  at  their  exit  from  the  spinal  canal. 

After  the  uterine  walls  have  been  weakened  by  these  lesions 
which  shut  off  the  nutrition,  then  the  exciting  cause,  such  as  ex- 
ertion, a  fall  backward  when  the  bladder  is  distended,  more 
readily  produces  a  displacement,  first,  a  retroversion  and  soon  a 
retroflexion  if  the  walls  are  weak. 

Retroflexion  is  rarely  congenital,  in  which  respect  it  con- 
trasts with  anteflexion.  It  is  frequent  in  multipara  (rare  in 
nullipara)  because  the  cause  is  especially  related  to  the  puerperal 
state.  During  the  puerperium  the  walls  are  large,  vascular  and 
very  soft.  The  ligaments  and  all  the  supports  are  weakened  on 
account  of  not  having,  in  such  a  short  time,  recovered  their  tone. 
If  the  bladder  is  much  distended  it  will  force  the  uterus  backward, 
and  if  this  is  frequently  repeated,  and  the  patient  lies  on  her  back, 
the  uterus  will  be  forced  back  and  perhaps  remain  permanently 
in  that  position. 

On  examination  of  the  patient  shortly  after  her  confine- 
ment, we  sometimes  find  that  the  uterus  is  lying  back  in  the  pelvis. 
The  intra-abdominal  pressure  which,  when  the  uterus  is  in  the 
normal  position  is  exerted  on  the  posterior  wall,  now  comes  to 
act  on  the  anterior  wall,  forcing  the  fundus  backward  and  down- 
ward. Each  straining  effort  forces  it  a  little  further  until  by 
degrees  it  is  retrofiexed. 

The  practice  of  putting  on  a  tight  abdominal  binder  after 
confinement  tends  to  force  the  uterus  downward  into  a  cramped 
position,  and  later  on  it  is  forced  backward,  and  this  is  especially 
true  if  the  patient  lies  a  great  deal  in  the  dorsal  position  during 
the  puerperium.     The  uterus  after  labor  remains  low  in  the  pelvis 


250  DISEASES   OF   WOMEN. 

for  about  twenty-four  hours.  After  that  time  it  should  rise 
AS  HIGH  AS  the  UMBILICUS.  If  the  uterus  is  normal  in  tone  it 
will  become  straightened  out  unless  held  down  by  a  "binder," 
If  the  bandage  is  applied,  or  if  the  uterus  is  very  weak  as  is  often 
the  case  in  tedious  labors,  it  remains  in  a  collapsed,  crumpled  con- 
dition, partly  out  but  mostly  in  the  true  pelvic  cavity.  This 
condition  interferes  with  drainage,  hence  the  great  liability 
to  puerperal  fever.  The  writer  always  advises  the  giving  of  a 
"lifting  up"  abdominal  treatment,  if  the  uterus  fails  to 
ascend,  for  the  purpose  of  straightening  the  uterine  canal.  This 
is  best  accomplished  by  placing  the  patient  on  the  side  and  mak- 
ing deep  pressure  just  above  the  symphysis  pubis  and  then  carry- 
ing the  hand  backward  and  upward,  thus  lifting  the  intestines 
and  partly  straightening  the  uterus;  it  usually  being  in  a  position 
of  anteflexion  soon  after  labor  is  completed.  The  author's  rule  in 
obstetric  work,  is  to  establish  free  drainage  of  the  lochia, 
thus  preventing  childbed  fever.  If  drainage  is  good  it  is  well  nigh 
impossible  for  a  fever  to  occur  if  any  care  whatever  is  taken. 

A  fibroid  tumor  on  the  anterior  wall  may,  by  its  growth 
force  the  uterus  backward,  thus  producing  a  retroflexion.  Un- 
equal involution  of  the  uterus,  when  the  placental  site  is  on  the 
anterior  wall,  causes  the  posterior  wall  to  contract  faster  than  the 
anterior,  thus  drawing  the  upper  part  backward. 

Adhesions  may  draw  the  fundus  backward  or  laterally, 
while  the  cervix  is  fixed  by  other  adhesions.  This  results  in  a  bad 
form  of  retroflexion.  The  adhesions  usually  follow  metritis  or  a 
perimetritis,  and  the  treatment  should  be  directed  to  absorb 
rather  than  break  them  up. 

After  considering  all  these  causes  the  most  important  is  the 
metritis,  which  softens  and  enlarges  the  uterine  walls.  To  the 
osteopath  this  usually  means  that  there  is  some  derangement  of 


AFFECTIONS    OF    THE    UTERUS.  251 

the  bony  framework  which  encloses  the  pelvic  organs,  shutting  off 
some  of  the  nutrition  or  nerve  force  that  should  be  transmitted 
through  the  numerous  foramina  to  the  pelvic  organs. 

SYMPTOMS.  The  symptoms  of  retroflexion  may  be  arranged 
in  three  groups ;  the  first,  including  those  which  are  more  or  less 
continuous;  the  second,  those  that  are  referred  to  the  menstrual 
period ;  and  third,  those  connected  with  the  function  of  repro- 
duction. 

Backache  is  one  of  the  common  symptoms  attending  any 
displacement,  but  especially  retroflexion.  It  may  be  a  dull  con- 
stant ache  or  it  may  be  an  actual  pain,  which  is  aggravated  by 
muscular  action  and  at  the  menstrual  period.  The  patient  usual- 
ly describing  it  in  this  way:  "My  back  feels  like  it  is  broken  or 
unjoin  ted  in  the  small  of  the  back  or  at  the  waist  line."  This  is 
WORSE  IN  THE  EVENING  if  the  patient  has  been  on  her  feet  during 
most  of  the  day.  There  is  a  weakness  or  a  distinct  pain  between 
the  SCAPULAE  which  is  increased  by  exercise  or  fatigue.  Finally 
the  patient  tells  you  of  a  drawing  sensation  in  the  neck;  the  head 
has  a  tendency  to  retract  ;the  eyeballs  become  tender,  or  in 
some  cases  there  is  a  distinct  ache  and  there  is  the  usual  ver- 
tical  HEADACHE. 

Sciatica  in  its  worse  form  is  often  produced  by  retroflexion 
of  the  uterus.  This  is  partly  the  result  of  pressure  on  the  sacral 
nerves  and  partly  due  to  the  inflammation  of  the  uterus  extend- 
ing to  the  nerve.  The  writer  has  cured  cases  of  synovitis  of  the 
knee  by  correcting  a  retroflexed  uterus.  Various  other  types  of 
neuritis  and  neuralgia  of  the  lower  limbs  result  from  retro- 
flexion. 

Metritis  with  its  symptoms  of  heaviness  and  distress  in  the 
pelvis,  is  present.  Tenderness  is  obtained  by  pressure  over  the 
uterus,  that  is,  at  a  point  just  above  the  symphysis  pubis.     Any 


252  DISEASES    OF   WOMEN. 

condition  producing  movement  of  the  uterus,  such  as  a  digital 
examination,  coition,  or  jarring  of  the  body,  causes  pain  in  the 
uterus. 

Chronic  peritonitis  with  its  adhesions  and  exudates,  ac- 
companies the  metritis  and  fixes  the  uterus  in  its  abnormal  posi- 
tion. Endometritis  is  present  with  its  disturbing  secretions. 
Dyspareunia  occurs  if  the  inflammation  is  very  marked.  Pain- 
ful or  difficult  defecation  results  from  either  the  inflamed 
condition  of  the  uterus,  or  the  pressure  of  the  uterus  against  the 
rectum.  This  gives  the  patient  the  sensation  of  a  loaded  bowel, 
and  the  repeated  attempts  to  empty  it,  are  often  accompanied 
by  tenesmus.  Passage  of  the  bowel  contents  through,  and  con- 
traction of  the  sphincter  muscles  around  an  inflamed  and  sensi- 
tive zone,  are  necessarily  accompanied  by  considerable  pain.  In 
case  that  constipation  complicates  retroflexion,  I  think  it  due,  in 
most  cases,  rather  to  the  relaxed  condition  op  the  sphincter 
MUSCLE  and  mucous  lining  of  the  rectum,  than  to  any  mechanical 
obstruction  produced  by  the  displaced  uterus.  The  pressure  of 
the  uterus  deadens  the  sensation  in  the  bowel  as  does  constant 
pressure  on  any  sensory  nerve. 

There  is  a  weak,  flabby  condition  of  the  sphincter  muscles 
in  chronic  cases  and  the  mucous  membrane  prolapses.  On 
making  a  rectal  examination  in  these  kind  of  cases,  the  finger  will 
meet  with  a  blind  obstruction,  the  lumen  of  the  bowel  being  very 
hard  to  discover.  I  have  examined  cases,  in  which  the  internal 
sphincters  had  prolapsed  so  that  they  approached  the  anal  open- 
ing, thus  occluding  the  bowel  at  that  point. 

Leucorrhea  accompanies  this  form  of  displaced  uterus,  if 
there  is  an  existing  endometritis.  The  blood  supply  of  the 
mucous  and  other  glands  is  impaired  in  quality,  it  being  venous 
in  character.     If  there_jWere  increased  arterial  supply,  the  physiol- 


AFFECTIONS  OF  THE  UTERUS.  253 

ogical  secretions  would  be  increased;  but  an  increased  amount  of 
venous  blood  produces  a  pathological  secretion  or  leucorrhea. 
If  the  case  is  chronic  and  the  uterine  and  vaginal  walls  are  soften- 
ed, leucorrhea  is  a  constant  symptom,  but  if  it  is  a  recent  case  it  is 
usually  absent. 

Dysmenorrhea,  though  not  so  common  as  in  anteflexion, 
is  an  important  symptom  of  retroflexion,  and  is  due  to  the  metri- 
tis or  inflammation  of  the  uterus,  or  to  the  obstruction  at  the 
point  of  flexion.  In  some  cases  it  is  due  to  both.  As  mentioned 
under  anteflexion,  there  would  be  very  little  pain  if  no  inflamma- 
tion accompanied  the  narrowed  condition  of  the  uterine  canal. 
When  there  is  narrowing,  obstruction  and  an  inflamed  condition, 
great  pain  is  experienced  when  the  uterus  contracts  in  its  effort 
to  overcome  the  obstruction  to  the  exit  of  the  menstrual  flow. 
This  dysmenorrhea  is  not  so  marked  as  that  found  in  anteflexion ; 
probably  on  account  of  the  patulous  condition  of  the  os  uteri  from 
pregnancy,  since  retroflexion  is  most  commonly  found  in  multi- 
para. 

If  there  is  marked  congestion,  Menorrhagia  will  be  a  symp- 
tom of  this  displacement.  On  account  of  the  obstruction  of  the 
return  flow  of  blood,  the  uterus  becomes  engorged  and  the  mens- 
trual flow  is  a  safety  valve  whereby  the  utervis  can  rid  itself  of 
this  extra  amount  of  blood. 

Sterility  is  sometimes  found,  and  is  due  to  an  altered  con- 
dition of  the  OS  and  cervix;  increased  mucous  secretion;  obstruc- 
tion of  the  Fallopian  tubes,  or  prolapsus  of  the  ovaries.  If  the 
fundus  is  bent  backward  very  far,  the  tubes  and  ovaries  must  be 
altered  in  position,  sometimes  to  such  an  extent  that  there  is 
suspension  or  destruction  of  their  function.  Frequently  the 
patient  will  tell  you  that  she  had  a  child  several  years  ago,  and 
after  that  she  suffered  with  leucorrhea,  pain  in  the  back,  irregu- 


254  DISEASES    OF    WOMEN. 

lar  menstruation,  and  has  never  conceived  again.  In  such  cases 
a  retroflexion  is  commonly  found.  After  conception  has  taken 
place  in  such  cases  there  is  a  further  risk  of  abortion.  Concep- 
tion may  take  place  in  a  retroverted  uterus  which  may  right 
ITSELF  as  soon  as  the  fetus  begins  to  grow  and  push  the  fundus 
out  of  the  pelvis,  which  is  about  the  third  month.  If  the  uterus 
does  not  right  itself,  or  if  the  mucous  membrane  is  in  a  pathologi- 
cal condition  which  prevents  the  ovum  from  being  firmly 
attached,  abortion  will  occur. 

The  SIZE  of  the  uterus,  that  is,  the  length  of  the  body  and 
size  of  the  cavity,  are  increased  in  retroflexion,  the  cavity  meas- 
uring about  three  inches  in  length.  The  posterior  wall  at  the 
point  of  flexion  is  thin  and  atrophied.  The  abdominal  pressure 
acting  on  the  anterior  wall,  forces  the  fundus  lower  into  the  pouch 
of  Douglas;  sometimes  it  rests  directly  on  its  floor.  The  bladder 
is  not  always  disturbed,  but  lacks  the  pressure  of  the  uterus  on  it, 
this  sometimes  causing  trouble. 

The  ureters  are  often  compressed,  this  giving  rise  to  renal 
trouble  or  a  pain  resembling  the  passage  of  a  renal  calculus. 

The  nerves  supplying  the  lower  limbs,  may  be  affected  by 
the  pressure  of  the  retroflexed  uterus  and  give  rise  to  pains  in 
THE  LOWER  EXTREMITIES.  There  may  be  only  a  sense  of  weak- 
ness with  no  particular  pain,  the  patient  complaining  of  feeling 
tired  in  the  limbs  after  a  slight  exertion  or  else  they  remain  cold 
a  great  deal  of  the  time. 

Abdominal  pain,  neuralgias  in  different  parts  of  the  body, 
nervous  dyspepsia  and  neurasthenia  are  usually  present.  Hys- 
teria in  all  its  peculiar  and  varied  forms,  sometimes  attends  this 
condition. 

Tenderness  is  found  along  the  sacro-iliac  synchondroses, 
sometimes  there  is  a  knott}^  feeling  in  the  muscles  and  lymphatics 


AFFECTIONS   OF  THE   UTERUS.  255 

at  this  point.  The  fifth  lumbar  is  frequently  found  to  be  tender 
on  palpation.  The  sacrum,  in  some  cases,  will  be  found  to  be 
prominent,  indicating  a  turning  at  the  sacro-iliac  junction. 
Since  the  inferior  hypogastric  plexuses  are  located  on  either  side 
of  the  uterus,  the  backward  displacement  will  certainly  disturb 
them  in  some  way;  by  stretching  the  nerve  filaments,  resulting 
either  in  inhibition  or  stimulation  of  them.  The  broad  liga- 
ments are  turned  almost  completely  over,  or  at  least  very 
badly  twisted.  This  of  a  certainty  causes  circulatory  changes 
in  the  pelvic  genitalia  resulting  in  ovarian,  tubal  and  uterine 
disturbances,  varying  from  congestion  to  suppuration,  this  de- 
pending upon  the  completeness  of  the  obstruction. 

DIAGNOSIS.  On  vaginal  examination  the  cervix  is  found 
rather  low  in  the  vagina,  its  direction  being  a  little  changed.  If  a 
retroversion  complicates  the  flexion,  the  cervix  instead  of  point- 
ing to  the  hollow  of  the  sacrum,  points  forward.  On  examina- 
tion of  the  posterior  fornix,  a  firm  body  is  felt  in  the  pouch  of 
Douglas;  this  is  the  fundus  or  body  of  the  uterus.  To  ascertian 
whether  this  body  is  the  uterus  or  a  tumor  the  cervix  is  moved 
at  the  same  time.  If  it  is  the  uterus  it  moves  when  the  cervix 
moves  unless  adhesions  exist.  The  angle  on  the  posterior  wall 
can  be  felt,. but  a  fibroid  tumor  may  exist  in  the  posterior  wall, 
and  in  order  to  differentiate  the  two,  the  bimanual  examination 
must  be  made  in  addition  to  the  digital  vaginal. 

First  try  and  see  if  the  uterus  is  in  normal  position ;  this  being 
done  by  pressure  exerted  in  the  anterior  fornix  with  the  internal 
finger  and  just  above  the  symphysis  with  the  external  hand.  If 
no  body  is  found  at  this  point,  it  is  indicative  that  the  uterus  is 
backward.  Then  place  the  internal  finger  behind  the  cervix, 
well  up  in  the  posterior  fornix;  with  pressure  exerted  upward,  m 
conjunction   with  deep  pressure  over  the  abdomen  with  the  ex- 


256  DISEASES   OF    WOMEN. 

ternal  hand,  the  retroflexion  can  be  felt  if  the  abdominal  wall  is 
thin  and  relaxed,  otherwise  it  cannot. 

If  in  doubt,  a  rectal  examination  should  be  made,  the 
position  of  the  uterus  can  then  be  palpated  if  there  is  no  ascent. 
This  examination  is  necessary  if  the  abdominal  walls  are  con- 
tracted or  very  thick.  Having  found  that  the  uterus  is  flexed, 
its  MOBILITY  should  be  tested  in  order  to  ascertain  as  to  whether 
or  not  it  is  held  down  by  adhesions ;  whether  the  fundus  is  caught 
under  the  promontory  of  the  sacrum;  or,  if  it  is  too  freely  movable. 

To  ascertain  the  mobility,  pressure  is  exerted  upward  on  the 
body  of  the  uterus;  it  should  yield  readily  if  not  fixed  by  adhe- 
sions. If  held  down  by  adhesions  or  caught  under  the  promon- 
tory of  the  sacrum,  considerable  force  is  necessary  to  move  it. 
By  examining  the  posterior  surface  of  the  uterus  either  through 
the  posterior  fornix  or  the  rectum,  the  adhesive  bands  can  be 
palpated.  I  have  felt  them  as  large  as  wheat  straws,  and  very 
tense  if  an  attempt  were  made  to  push  the  uterus  forward.  If 
such  exist,  they  must  be  either  absorbed  or  broken  up  before  a 
replacement  can  be  effected.  Often  the  uterus  seems  glued,  as 
it  were,  to  the  sacrum  or  bowel.  In  such  cases,  no  adhesive  bands 
can  be  felt  but  the  uterus  seems  to  be  securely  fastened  and  is  not 
moved  by  ordinary  pressure.  Percussion  over  the  sacrum,  or  a 
vigorous  shaking  of  the  patient  while  in  the  knee-chest  position ,  is 
often  sufficient  to  overcome  such  adhesions. 

The  sound  is  sometimes  used  to  differentiate  between  a  flexion 
and  a  tumor  on  the  posterior  wall,  but  its  use  should  be  deferred 
until  all  other  methods  have  failed;  and  even  then  as  an  experi- 
ment its  use  is  very  seldom  indicated,  although  many  physicians 
do  advise  it. 

Care  must  be  taken  not  to  mistake  a  fecal  impaction  for  a 
retroflexion.     The  fecal  matter  felt  through  the  posterior  wall  of 


AFFECTIONS    OF    THE    UTERUS.  257 

the  vagina  may  also  be  mistaken  for  a  tumor,  especially  if  the 
patient  has  chronic  constipation,  in  which  condition  the  feces  are 
very  hard. 

A  deposit  in  the  pouch  of  Douglas  may  at  first  be  mistaken 
for  the  fundus,  but  locating  the  fundus  at  a  different  place,  clears 
up  the  diagnosis.  Sometimes  the  ovary  prolapses  into  the  pouch 
of  Douglas,  or  an  ovarian  cyst  may  be  found  in  this  region.  The 
cyst  can  be  diagnosed  by  its  elasticit}^  and  softness,  and  the  sub- 
jective symptoms. 

PROGNOSIS.  The  prognosis  depends  upon  the  amount  of 
inflammation ;  length  of  standing  of  the  case,  and  whether  or  not 
it  is  a  reducible  flexion.  If  it  is  one  of  recent  occurence,  and 
there  is  not  much  loss  of  tonicity,  the  prognosis  is  good;  but  if  of 
long  standing  and  there  is  a  metritis  or  atrophy,  it  is  poor.  If  the 
flexion  can  not  be  entirely  overcome,  relief  can  usually  be  given  a 
patient  by  removing  the  inflammation  and  tenderness. 

TREATMENT.  The  treatment  of  retroflexion  is  best  dis- 
cussed under   three  heads;  first,  replacement   of   the  organ; 

SECOND,     KEEPING    IT    IN    PLACE    AFTER    IT    HAS    BEEN   REPLACED; 

THIRD,  RELIEF  OF  THE  SYMPTOMS  where  replacement  is  impossible. 
The  first  thing  to  notice  is  the  amount  of  inflammation  and 
whether  or  not  the  uterus  can  be  replaced.  The  obstacles  to  re- 
placement are  fibroid  tumors,  adhesions  and  inflammatory  con- 
ditions, which  make  the  parts  too  sensitive  to  be  moved.  These 
conditions  must  be  overcome,  or  at  least  partially  reduced,  before 
the  uterus  can  be  replaced. 

The  treatment  for  fibroid  tumors  will  be  given  in  another 
paragraph. 

Adhesions  are  best  treated  by  producing  absorption  of  them, 
which  is  done  b}^  correcting  the  disturbances  of  the  circulation. 
They  are  the  result  of  an  inflammatory  exudate,  and  the  inflamma- 

17 


258  DISEASES    OF    WOMEN. 

tion  is  the  result  of  a  disturbed  blood  supply.  Gentle  force  can  be 
used  to  break  them  up,  but  care  must  be  taken  lest  the  inflam- 
mation be  increased  or  a  hemorrhage  result,  which  would  bring 
on  peritonitis.  If  there  is  great  tenderness  in  and  around 
the  uterus,  it  can  be  lessened  by  gentle  treatment  around  the 
uterus;  principally  above  it.  This  lifts  up  the  intestines  and 
helps  the  drainage  of  the  blood  out  of  the  uterus.  Direct  manip- 
ulation, unless  very  light,  over  the  point  of  inflammation,  is  not 
indicated  and  sometimes  makes  the  condition  worse. 

Sudden  retroflexion  occasionally  occurs.  It  is  due  to  a  weak- 
ened uterus  and  supports,  plus  some  exciting  cause;  such  as  a 
twist,  strain,  sudden  exertion,  or  in  fact  anything  causing  a  sudden 
increase  in  the  intra-abdominal  pressure.  It  gives  rise  to  very 
acute  symptoms  and  frequently  produces  unconsciousness.  I 
have  been  called  to  see  cases  in  which  the  patient  appeared  to  be 
violently  insane.  In  some  of  these  cases  the  patients  were  at- 
tempting to  bite  and  scratch,  or  injure  in  any  way  possible,  who- 
ever came  near;  also  pulling  out  their  own  hair  by  the  handsfull. 
Correcting  the  uterine  displacement  seldom  failed  to  brmg  the 
patient  to  consciousness,  and  that  almost  instantly. 

It  is  very  hard  to  explain  the  wide  and  varied  effects  of  acute 
retroflexion  which  seem  to  be  out  of  all  proportion  to  the  cause, 
yet  such  effects  occur.  The  author  has  long  since  learned  to 
examine  the  uterus  in  cases  of  sudden  loss  of  consciousness, 
accompanied  by  violent  symptoms  as  indicated  in  the  above 
mentioned  cases. 

REPLACEMENT.  There  are  several  methods  employed  in 
replacing  a  retroflexed  uterus.  The  one  method  that  I  use  a 
great  deal  is  to  place  the  patient  in  the  Sims,  or  semi-knee  chest 
position  and  introduce  one  or  two  fingers  into  the  vagina,  two 
being  better    and  are   used  if  possible.     By  exerting   a  steady 


AFFECTIONS  OF  THE  UTERUS. 


259 


pressure  against  the  fundus,  v.hich  is  palpated  through  the  pos- 
terior fornix,  it  can  be  gradually  straightened  from  its  retroflexed 
condition. 


Fi(i.  79. — Mnuu.il  repliicenieiit  I >f  retroflexed    uterus.     Ist    step. 

If  the  uterus  is  quite  firm  and  retroversion  complicates  the 
retroflexion,  which  it  usually  does,  pressure  against  the  fundus, 
coupled  with  traction  on  the  cervix  are  usually  sufficient  to  rotate 
the  uterus  into  the  normal  position.  Traction  on  the  cervix  is 
of  little  value  unless  the  uterus  Is  quite  firm,  since  it  bends  at  the 


260  DISEASES    OF    WOMEN. 

point  of  flexion  without  moving  the  fundus.  Pressure  with  the 
external  hand,  whereby  the  uterus  is  forced  down  within  grasp 
of  the  vaginal  fingers,  is  very  helpful.  In  some  cases  it  is  advis- 
able to  balloon  the  vagina  and  then  instruct  the  patient  to  cough, 


Fig.  80. — .Vlanual  replficenient  of  retroflexion.    2nd  step. 

by  which  a  suction  force  Is  exerted  and  the  uterus  drawn  into 
place. 

After  it  has  been  raised  it  can  be  grasped  by  the  external 
hand,  if  the  abdominal  wall  is  thin,  and  then  having  the  uterus 
between  the  two  hands  it  can  be  readily  replaced.  In  making 
pressure  with  the  external  hand  commence  quite  high,  as  high  as 
the  promontory    of  the  sacrum  and  work  downward  toward  the 


AFFECTIOXS    OF   THE    UTERUS. 


261 


fundus.     If  the  pressure  is  made  low  down,  the  tissues  are  made 
more  tense  and  the  uterus  forced  farther  back. 


Fig.  81. — Mauual  replacement  of  retroflexion.    3rd  step. 


If  the  uterus  moves  upward  when  an  attempt  is  made  to  get 
the  vaginal  finger  behind  it,  resort  will  have  to  be  made  to  a  rectal 
treatment.     Through  the  rectum,  the  entire  fundus  can  be  felt; 


262 


disease:s  of  women. 


and  by  pressure  exerted  directly  on  it  through  the  anterior  rectal 
wall,  it  can  be  bent  forward  far  enough  to  be  grasped  by  the  ex- 
ternal hand.     Again  the  recto-vaginal  method  is  used   in  some 


Fig.  82. — Showing  manner  of  adjusting  wire  to    uterus  in  retroflexion. 
The  cervix  is  fixed  by  finger  passed  tlirougli  loop  of  wire.    (First  step.) 

cases.  This  is  performed  by  placing  the  index  finger  in  the  vagina 
and  the  second  finger  in  the  rectum,  then  by  steadying  the  cervix 
with  the  index  finger  the  fundus  is  pushed  forward  by  the  rectal 
finger.     I  seldom  Use  this  method. 


AFFECTIONS  OF  THE  UTERUS.  263 

The  wire  repositor  invented  by  Dr.  Still,  can  be  used  to  ad- 


Fig.  83. — Showing  manner  of  replacing  retroflexion  with  wire.    (Second  step.) 

vantage  in  correcting  this  form  of  displacement.     The    instru- 
ment is  introdviced  and  the  loop  adjusted  around  the  cervix.  By 


264  DISEASES    OF    WOMEN. 

lifting  directly  upward  when  the  patient  is  in  the  dorsal  position 
or  pulling  directly  forward  when  the  patient  is  in  the  right  latero- 
prone  position,  the  uterus  will  be  partly  forced  through  the  loop 
of  the  instrument  and  will  be  almost  entirely  straightened.  The 
INDEX  FINGER  should  be  introduced  and  the  cervix  held  in  the 
LOOP  if  any  trouble  is  experienced  in  keeping  it  in  the  loop.  Then 
by  exerting  pressure,  as  in  replacement  of  prolapsus,  the  uterus 
can  be  brought  in  position.  The  advantage  lies  in  the  fact  that 
the  end  of  the  loop  being  m  the  posterior  fornix,  pressure  can  be 
made  higher,  that  is,  more  directly  against  the  fundus  than  can 
be  made  with  the  unaided  finger.     The  patient  should  then  rest 


Fig.  84.— Volsella. 

for  awhile  on  her  side  or  chest,  until  the  uterus  adjusts  itself  to 
the  changed  relations. 

The  genu-pectoral  position  is  really  the  best  one  to  use  in 
replacing  retro-deviations  not  complicated  by  adhesions.  Grav- 
ity aids  in  the  operation  and  usually  very  little  artificial  help  is 
necessary.  With  one  or  two  fingers  in  the  vagina,  pressure,  if 
exerted  on  the  posterior  uterine  wall,  will  replace  it.  In  some 
cases  the  posterior  vaginal  wall  is  retracted,  thus  permitting  the 
entrance  of  air,  which  forces  the  uterus  downward;  it  sometimes 
returning  to  the  normal  position.  The  reason  for  this  is  that  when 
a  patient  is  in  the  genu-pectoral  position,  the  weight  of  the  in- 
testines is  taken  from  the  pelvic  viscera  on  account  of  the  re- 
traction of  the  intestines.     This  leaves  a  partial  vacuum  in  the 


AFFECTIONS    OF    THE    UTERUS.  265 

pelvic  cavity  and  by  admitting  air  into  the  vagina  the  uterus 
will  be  forced  downward  by  atmospheric  pressure. 

If  the  uterus  sags,  that  is,  if  the  flexion  is  exaggerated  as  it 
is  in  many  cases,  volsella  are  used  by  surgeons  if  replacement  is 
effected  while  in  this  position.  By  means  of  this  instrument  the 
cervix  can  be  drawn  up,  thus  allowing  the  fundus  to  escape  from 
under  the  promontory  of  the  sacrum  by  which  the  fundus  is  held. 
If  volsella  are  not  used  after  the  vagina  has  become  ballooned,  it 
becomes  necessary  to  use  the  rectal  method  or  have  the  patient 
assume  the  erect  posture  before  further  attempts  at  replacement 
are  made.  If  the  fundus  is  adhered,  the  knee-chest  positon  only 
exaggerates  the  flexion  and  on  vaginal  examination  the  cervix 
will  be  found  quite  high,  sometimes  entirely  out  of  reach  of  the 
examining  finger.  If  the  fundus  has  been  caught  behind  the 
promontory  of  the  sacrum  it  can  be  loosened  by  the  rectal  treat- 
ment. As  in  all  downward  and  backward  displacements,  the  patient 
should  rest  for  awhile  after  the  treatment,  on  her  side  or  chest. 

The  SOUND  is  the  last  resort  and  is  used  after  the  above 
me'thods  have  failed,  which  of  course  is  the  exception.  If  the 
patient  has  a  very  thick  or  contracted  abdominal  wall,  resort  to 
the  sound  will  probably  have  to  be  made,  as  it  is  very  hard  to 
manipulate  the  uterus  if  such  a  condition  exists.  After  a  proper 
preparation  of  the  sound,  the  patient  should  be  placed  in  the  Sims 
position;  with  the  right  index  finger,  locate  the  os  uteri.  Then 
with  the  sound  in  the  left  hand,  with  the  concavity  backward  (an 
inflexible  steel  sound  being  the  best)  it  is  pushed  without  rota- 
tion directly  into  the  uterine  canal.  After  it  has  been  introduced 
the  sound  is  rotated  by  carrying  the  handle  through  a  wide  arc 
so  as  to  prevent  rotation  of  the  point,  which  would  injure  the 
mucous  membrane  of  the  uterus.  The  handle  is  then  gradually 
and  gently  brought  backward,  thus  forcing  the  uterus  into  place. 


266  DISEASES    OF    WOMEN. 

The  replacement  can  certainly  be  effected  in  this  way,  but  the 
most  careful  precautions  will  not  prevent  this  method  of  pro- 
ceedure  from  producing  irritation  of  the  endometrium;  hence 
should  not  be  used  if  replacement  can  be  effected  in  any  other 
way. 

After  all,  the  hands  are  the  best  repositors  in  ordinary 
cases.  The  bimanual  method  has  several  advantages  over  all 
methods.  First,  it  is  safer  and  more  convenient  and  not  so  likely 
to  be  followed  by  endometritis;  second,  the  lever  action  of  a 
sound  is  avoided,  whereby  an  undue  amount  of  force  may  be  used; 
and  third,  the  operator  feels  every  move;  the  operation  being 
constantly  under  his  control,  and  on  noting  points  of  resistance  he 
stops  before  too  much  force  is  used. 

HOW  TO  KEEP  THE  UTERUS  IN  PLACE  AFTER  RE- 
PLACEMENT. As  in  anteflexion,  the  uterine  walls  must  be 
strengthened;  but  in  addition,  in  the  case  of  retroflexion,  the 
round  LIGAMENTS  must  be  shortened  to  hold  the  uterus  in  posi- 
tion after  it  has  been  replaced.  By  correcting  bony  lesions  that 
cause  a  weakening  of  the  uterine  walls  or  their  supports,  and  by 
relieving  the  congestion,  by  removing  the  obstruction  to  the 
proper  return  flow  of  blood  before  the  attempt  is  made  to  replace 
it;  the  uterus  will  probably  be  held  in  position  after  it  is  replaced. 
Usually  it  does  little  or  no  good  to  replace  the  organ  before  its 
supports  have  been  strengthened,  although  in  some  cases  it  helps 
to  relieve  the  congestion  and  inflammation  which  exist.  Fre- 
quent local  treatments  to  replace  the  uterus,  as  practiced  by  a 
great  many,  are  wrong.  They  keep  the  parts  irritated  and  do 
not  strengthen  the  supports  but  rather  weaken  them. 

The  patient  should  be  instructed  to  not  let  the  bladder  get 
distended  or  else  the  uterus  will  be  forced  back  into  its  former 
position  on  account    of  the  weakness  of  the  round  ligaments. 


AFFECTIONS    OF    THE    UTERUS.  267 

Coition  is  contra-indicated  before  the  normal  tonicity  has  re- 
turned to  the  parts.  Assuming  the  genu-pectoral  position  sev- 
eral times  daily  is  very  helpful  in  these  kinds  of  cases.  The  pa- 
tient should  avoid  the  wearing  of  tight  clothes  or  bands,  for  they 
force  the  weakened  uterus  backward  by  increasing  the  intra- 
abdominal pressure.  Strains,  lifting  of  weights,  falls,  or  the 
doing  of  anything  which  suddenly  increases  the  intra-abdominal 
pressure,  readily  displace  the  uterus  again,  and  should  be  avoided 
on  account  of  the  weakness  of  the  round  ligaments. 

The  most  important  is  to  correct  the  bony  lesions  found, 
since  they  are  the  real;  the  predisposing  causes.  The  uterus 
must  be  nourished  and  strengthened;  but  this  can  not  be  done  if 
these  lesions  which  shut  off  the  blood  supply  are  not  corrected. 
Thus  they  must  be  adjusted  if  a  permanent  cure  is  expected,  or 
if  the  uterus  is  to  be  kept  in  place  after  it  is  replaced. 

Pessaries  have  been  recommended,  but  I  never  use  them  in 
this  kind  of  displacement,  for  it  can  be  corrected  a  great  deal 
better  without  them.  If  an  artificial  support  is  necessary,  a 
tampon  of  lamb's  wool  should  be  used.  A  single  tampon  placed 
in  the  posterior  fornix  will  often  hold  the  uterus  in  position.  A 
chain  tampon  is  better  in  the  average  case,  because  the  pressure 
is  the  better  distributed. 

Operations  have  been  devised  whereby  the  uterus  is  fixed 
to  the  abdominal  wall,  or  the  round  ligaments  shortened.  The 
first  is  performed  in  two  way;  either  by  an  abdominal  incision 
which  is  called  abdominal  hj^'sterorraphy ;  or  through  the  vagina, 
this  being  called  vaginal  hysterorraphy.  The  operation  for 
shortening  the  round  ligaments  is  called  Alexander's  operation. 
Only  mention  will  be  made  of  these  operations  since  operative 
gynecology  is  not  practiced  and  seldom  advised  by  the  osteopathic 
physician. 


268  DISEASES    OF    WOMEN. 

It  seems  that  our  modern  gynecologists  treat  all  forms  of 
retroflexion  alike,  regardless  of  the  many  different  causes  pro- 
ducing them.     Pessaries  are  introduced  or  operations  performed, 


Fig.  83. — Retroversion  of  the  uterus,     let  degree. 

which  are  sometimes  far  more  dangerous  and  cause  more  trouble 
than  the  original  disturbance  for  which  the  treatment  was  given. 
At  the  conclusion,  the  woman  is  told  that  "the  uterus  is  now  in 
place"  and  that  her  symptoms  ought  to  leave.  The  woman,  not 
caring  where  the  uterus  is  so  long  as  she  is  free  from  pain,  suffers 


AFFECTIONS  OF  THE  UTERUS.  269 

on,  unless  the  cause  has  been  removed.  I  know  of  no  kind  of 
cases  that  so  strictly  belongs  to  the  osteopathic  field,  since  we  cure 
so  many  where  others  fail.  The  cause  of  the  trouble  in  the  indi- 
vidual case  must  be  found  and  corrected  or  else  the  routine  treat- 
ments are  in  vain,  or  at  least  are  only  palliative  and  serve  to  give 
only  temporar}^  relief. 

RETROVERSION.  Retroversion  is  that  form  of  displace- 
ment of  the  uterus  in  which  the  fundus  is  turned  backward  and 
the  cervix  forward,  changing  the  uterine  axis  but  not  bending 
the  canal.  It  is  frequently  associated  with  retroflexion,  and  the 
causes,  in  a  great  many  cases,  that  produce  the  one  will  produce 
the  other.  It  is  recognized  as  an  early  stage  of  prolapsus,  in  fact 
it  is  called  the  first  stage  ofprolapsus  uteri;  yet  slight  prolapsus 
is  PRIMARY  or  else  the  fundus  could  not  tip  back  very  far  on 
account  of  the  promontory  of  the  sacrum.  Sometimes  it  is 
rotated  so  far  backward  that  the  fundus  lies  in  the  hollow  of  the 
sacrum  with  the  cervix  pointing  forward. 

In  this  displacement,  the  intra-abdominal  pressure  is  directed 
on  the  fundus  or  anterior  wall  of  the  uterus,  which  exaggerates 
the  condition  and  promotes  prolapsus.  It  is  a  form  of  displace- 
ment which  most  frequently  comes  on  suddenly,  or,  as  in  the 
most  chronic  cases,  it  comes  on  gradually  as  the  result  of  the 
gradual  relaxation.  It  is  the  forerunner  of  retroflexion.  The 
uterus  is  first  retroverted,  then  its  position  weakens  the  support 
of  the  fundus  and  it  gradually  bends  backward  and  downward. 

There  are  three  accepted  degrees  of  retroversion.  In  the 
first  degree,  the  long  axis  of  the  uterus  is  in  line  with  the  axis  of 
the  vagina.  In  the  second  degree,  the  axis  of  the  uterus  occupies 
an  angle  of  one-hundred  and  thirty  degrees  to  that  of  the  vagina, 
and  in  the  third  degree,  an  angle  of  ninety  degrees  to  that  of  the 
vagina;  or  in  other  words  the  uterus  is  turned  as  far  backward 


270 


DISEASES    OF    WOMEN. 


as  it  should  be  forward.     There  are  many  minor  degrees  of  re- 
troversion between  the  limits  mentioned  above. 

CAUSES.     The  most  frequent  causes  are  those  which  put  a 
sudden  strain  on  the  round  and  sacro-uterine  ligaments.     If  a 


Fig.  8(i. — Retroversion  of  uterus.     (Bad  form.) 

patient  should  suddenly  slip,  or  lift  a  weight  while  in  a  stooped 
position,  it  very  frequently  brings  on  an  acute  retroversion.  I 
have  seen  cases  that  resulted  from  coughing  or  turning  suddenly 
over  in  bed.     Sudden  falls  on  the  buttocks,  such  as  would  result 


AFFECTIONS    OF   THE   UTERUS.  271 

from  some  one  pulling  a  chair  from  beneath  a  patient  in  the  act 
of  sitting  down,  will  cause  it  in  nearly  every  instance.  Jumping 
from  a  bicycle,  alighting  very  hard  on  the  feet,  or  any  jar  of 
the  body,  has  a  tendency  to  produce  this  kind  of  uterine  displace- 
ment. This  is  especially  true  if  the  bladder  is  distended  at  the 
time  of  the  strain  or  fall.  I  have  known  confirmed  invalids  who 
dated  their  trouble  back  to  the  time  when  they  strained  them- 
selves by  carrying  a  bucket  of  water.  I  recently  had  under  my 
care  a  lady,  who  had  a  backward  fall  on  the  ice  resulting  in  a  retro- 
version which  has  made  her  a  chronic  invalid. 

These  displacements  the  more  easily  occur,  if  any  bony 
lesion  exists  which  has  weakened  the  supports.  If  the  bony 
pelvis  and  lumbar  spine  are  properly  adjusted,  retroversion  is 
not  likely  to  occur;  or  at  least  it  will  occur  with  difficulty,  even 
if  there  is  a  fall  or  heavy  strain,  but  when  it  is  once  thrown  back- 
ward regardless  of  whether  or  not  lesions  exist,  the  abdominal 
pressure  tends  to  force  it  still  further  backward  and  downward. 

These  lesions  predispose  to  displacement  by  so  weakening 
the  supports  that  the  exciting  cause  the  more  readily  acts.  The 
most  common  lesions  are  a  subluxated  innominate,  sacrum. coccyx 
and  particularly  lesions  of  the  lumbar  vertebrae  should  be  con- 
sidered of  very  great  importance  as  causative  factors  in  retro- 
version, as  well  as  in  any  other  form  of  uterine  displacements. 

A    WEAKENING    OF    THE    UTERO-SACRAL     LIGAMENTS    permits 

the  lower  part  of  the  uterus  to  sag  down  and  the  upper  part  to  be 
rotated  backward.  This  relaxation  of  the  utero-sacral  ligaments 
precedes  nearly  all  cases  of  gradual  displacement.  This  permits 
the  cervix  to  sink  downward  and  forward,  simultaneously.  Un- 
less some  downward  movement  takes  place,  the  average  sized 
uterus  can  not  rotate  backward  to  any  marked  extent  on  account 
of  the  sacral    promontory.     This  relaxation  is  the  result    of    a 


272 


DISEASES    OF    WOMEN, 


displacement  of  the  sacrum,  to  which  these  ligaments  are  at- 
tached; lesions  in  the  lumbar  region,  and  intra-pelvic  diseases, 
such  as  subinvolution  and    inflammation,   which  affect  all  the 


Fig.  87. — RetrDverelon  of  uterus.    2nd  degree.    Showing  direction  of 
abdooiinal  pressure  and  position  of  intestines. 


pelvic  ligaments.     If  a  distended  condition  of  the  bladder  exists 
as  shown  in  Fig.  88  it  increases  tendency  to  backward  rotation. 
Prolapse  of  the  bladder  and  rectum  have  a  tendency  to  pro- 
duce   retroversion.     Relaxation    of    the    perineum    and    vaginal 


AFFECTIONS    OF   THE    UTERUS, 


273 


walls  are  found  in  nearly  all  chronic  cases,  probably  as  a  cause 
rather  than  an  effect.  The  non-return  of  the  uterus  to  its  normal 
form  and  position  during  the  puerperium  is  a  cause  of  retroversion 


Fig.  88 — Uterus  forced  back  in  distention  of  bladder. 

in  multipara.  A  knowledge  of  the  condition  of  the  uterus  will 
explain  the  occurrence  of  this  displacement  during  the  puer- 
perium. In  the  first  place  the  two  factors,  increased  weight 
and  relaxed  supports  are  present.     By  permitting  the  patient 

18 


274  DISEASES   OF   WOMEN. 

to  lie  on  the  back  too  much,  or  allowing  the  nurse  to  put  on  a 
tight  abdominal  bandage  (which  by  the  way,  is  an  abomination) 
the  uterus  is  kept  near,  or  forced  backward  against,  the  sacrum. 

Fibroid  tumors  on  the  anterior  wall  of  the  uterus  force  it 
back  in  retroversion  as  well  as  in  retroflexion.  There  is  marked 
rigidity  in  such  cases  in  the  entire  uterus  plus  the  usual  indica- 
tions of  fibroids. 

SYMPTOMS.  The  symptoms  are  very  similar  to  those  of 
retroflexion;  rectal  disturbances,  deranged  menstruation, 
abnormal  secretions,  bearing  down  sensation  which  is  worse 
on  standing  or  walking,  pain  over  the  sacrum,  sometimes  coccy- 
DYNiA  and  aching  in  limbs,  and  the  reflex  phenomena. 
The  patient  may  have  headache,  hemicrania,  pain  in  eyeballs, 
intercostal  neuralgia,  gastralgia,  or  other  visceral  derangements. 

The  most  common  of  the  reflex  phenomena  are  vertical  and 
occipital  headache,  megrim,  pain  between  the  shoulders,  nausea 
and  spinal  irritation.  In  cases  in  which  it  comes  on  suddenly, 
there  will  be  the  sensation  of  something  having  "given  away." 
backache  and  reflex  disturbances,  such  as  nausea,  and  vomit- 
ing, headache  and  pain  in  the  abdomen.  Instead  of  dysmenorrhea 
a  mild  foim  of  menorrhagia  more  frequently  prevails.  The  cer- 
vix may  irritate  the  bladder  by  direct  pressure  and  cause  frequent 
micturition,  but  this  is  the  exception  rather  than  the  rule. 

The  pressure  exerted  against  the  rectum,  increases  the 
tendency  to  constipation  or  it  interferes  with  the  rectal  circu- 
lation, on  account  of  which  many  rectal  diseases  result,  such  as 
rectal  ulcers,  piles,  tenesmus,  prolapsus  of  the  bowel  and  eversion 
of  the  anus. 

Leucorrhea  is  present  on  account  of  the  congestion  of  the 
uterine  and  vaginal  walls.  In  recent  cases,  the  pain  is  very  fre- 
quently referred  to  the  region  of  the  stomach,  small  intestines. 


AFFECTIONS    OF  THE    UTERUS.  275 

gall  bladder,  or  to  some  organ  even  higher  m  the  abdommal  cav- 
ity. There  is  cramping  of  the  abdominal  muscles  and  tender- 
ness over  the  entire  abdomen. 

There  are  quite  a  number  of  conditions  complicating  retro- 
version. A  PROLAPSUS  of  a  varying  degree  is  present  in  most 
cases.  This  is  due  to  a  change  of  position  of  uterus,  its  axis 
being  in  a  line  with  axis  of  the  vagina,  and  to  relaxation  of  sup- 
ports. Adhesions  are  commonly  found.  The  pressure  of  the 
uterus  on  the  sensitive  peritoneum  is  very  likely  to  irritate  it  and 
set  up  INFLAMMATION,  the  result  being  an  adhesion,  unless  the 
uterus  is  replaced.  The  ovaries  and  tubes  are  carried  back 
with  the  uterus,  hence  their  function  is  impaired.  There  is 
usuall}'  inflammation  of  the  uterus  and  peritoneum,  which 
if  present  when  the  ovaries  and  tubes  are  in  the  pouch  of  Douglas, 
results  in  adhesions.  Rectal  troubles  as  mentioned  above,  are 
frequent,  such  as  constipation,  diarrhea,  prolapsus  of  bowel, 
tenesmus  and  hemorrhoids,  all  of  which  often  follow  from  pressure 
against  the  rectum.  Metritis  and  endometritis  are  present  m 
most  cases  of  backward  displacement.  This  is  due  to  circulatory 
changes  resulting  from  the  displacement. 

Diagnosis.  The  diagnosis  is  made  by  locating  the  cervix 
low  down  in  the  vagina  and  pointing  tow\\rd  the  outlet  or 
symphysis  pubis.  The  finger  passed  into  the  posterior  fornix, 
discloses  a  hard,  round  mass,  continuous  with  the  cervix  and  rest- 
ing against  the  rectum.  By  the  bimanual  method  the  fundus  is 
not  fovmd  in  its  normal  position,  that  is,  it  is  not  found  on  palpat- 
ing through  the  anterior  fornix. 

By  the  rectal  examination  the  fundus  and  body  are  plainly 
felt  resting  against  the  rectum.  The  uterus  is  usually  found  to 
be  rigid  and  fixed  in  its  position.  I  have  seen  a  great  many  cases 
in  which  the  uterus  entirely  occluded  the  lumen  of  the  bowel  and 


276  DISEASES    OF    WOMEN. 

had  to  be  forced  forward  before  the  finger  could  be  introduced 
into  the  rectum.  A  fibroid  tumor  on  the  posterior  uterine  wall 
may  cause  rectal  symptoms,  but  the  direction  of  the  uterine  axis 
as  demonstrated  by  the  position  of  the  cervix  and  fundus,  depth 


Fig.  89. — Manual  replacement  of  retroverted  uterus  with  patient  on  left  si<le.   (1st  step.} 

of  uterine  cavity,  and  the  conjoined  examination,  will  clear  up 
the  diagnosis. 

TREATMENT.  In  cases  in  which  there  is  retention  of  tone 
in  the  pelvic  floor,  vaginal  and  abdominal  walls,  and  the  uterus 
with  its  ligaments,  and  in  cases  in  which  the  displacement  came 
on  suddenly,  the  treatment  consists  of  replacement.  Such  cases 
are  found  principally  in  nullipara  . 


AFFECTIONS  OF  THE  UTERUS.  277 

In  cases  in  which  all  the  supports  are  relaxed  and  weak, 
and  the  displacement  is  the  result  of  causes  more  or  less  continu- 
ous for  quite  a  long  while,  the  primary  treatment  is  one  directed 
to  RESTORE  TONE  to  the  support  AFTER  WHICH,  replacement  of 


Fig.  90. — Manual  replacement  of  retroverted  uterus.   (2nd  step.) 

the  uterus.  Yet  in  such  cases  it  is  well  to  replace  the  organ  from 
time  to  time,  as  this  helps  to  relieve  the  congestion,  lessens  its 
weight,  hence  assists  in  restoring  strength  to  the  pelvic  floor. 
Replacement  is  effected  in  the  ways  similar  to  those  mentioned 
under  the  head  of  replacement  of  retroflexion. 

Pressure  exerted  against  the  posterior  uterine  wall  by  means 
of  the  index  finger,  either  through  the  posterior  fornix  or  anterior 
rectal  wall,  is  a  method  I  most  commonly  use  at  first  to  determine 


278 


DISEASES   OF   WOMEN. 


the  extent  of  adhesions  and  size  of  the  uterus.  If  it  cannot  be 
replaced  in  this  way  I  place  the  patient  in  the  semi-knee  chest 
position  and  introduce  two  fingers  in  the  vagina.     Pressure  is 


Fig.  91. — Manual  replacement  of  retroverteil  uterus  completed.    The  cervix  Is  forced 
as  high  as  possible  and  the  intestines  puslied  behind  uterus  thus  preventing 

recurrence. 


AFFECTIONS    OF    THE    UTERUS. 


279 


exerted  against  the  posterior  uterine  wall,  through  the  posterior 
fornix  by  the  middle  finger.  Traction  backward  on  the  cervix 
with  index  finger  tends  to  pry  the  uterus  forward.  Combining 
the  two,  that  is,  pressure  forward  on  the  body  and  traction  back- 


FiG.  92. — Replacing  retroverted  uterus  with  wire,  finger  in  vagina.    Ist  step. 
Patient  on  right  side. 

ward  on  cervix,  the  utervis  is  rotated  around  the  fixed  point, — the 
attachment  of  the  utero-sacral  ligaments. 

If  adhesions  are  present  they  can  be  gradually  broken  up  by 


280 


DISEASES    OF    WOMEN. 


this  method.  In  some  cases  iii  which  the  fundus  seems  glued  to 
the  sacrum  it  is  hard  to  get  pressure  high  up  that  is  sufficient  to 
push  the    fundus  forward.     In  such  cases  the   "Okl  Doctor's" 


Fig.  93. — Replacing  retroversion  with  wire  repositor.    2nd  step. 

wire  is  a  handy  substitute;  with  it  pressure  can  be  exerted  high 
up  against  the  body  in  the  posterior  fornix,  and  the  uterus  forced 
forward. 

Sometimes  simply  admitting  air  into  the  vaginal  cavity  will 
cause  the  uterus  to  resume  its  normal  position,  unless  there  are 
adhesions,  or  unless  it  is  caught  behind  the  promontory  of  the 
sacrum.  If  these  methods  fail,  and  they  seldom  do,  a  sound  is 
commonly  used;  the  replacement  being  accomplished  by  this 
method.  To  keep  the  uterus  in  place  let  the  patient  rest  either 
on  her  face  or  side  as  long  as  possible  after  the  treatment  and  avoid 
the  conditions  that  were  primarily  responsible  for  the  displace- 
ment. 


AFFECTIONS   OF   THE    UTERUS.  281 

The  obstacles  preventing,  or  making  replacement  difficult, 
are  inflammation  of  the  uterus  and  adnexa,  and  adhesions  or 
incarceration  of  the  fundus  under  the  promontory  of  the  sacrum. 
Adhesions  can  gradually  be  overcome  by  repeated  attempts  at 


Fig.  94. — Replacement  of  retrovertert  uterus  with  wire  repositor  completed.    Pa- 
tient on  right  side.    Note  position  of  handle. 

replacement  whereby  the  bands  are  stretched  or  broken.  In 
cases  of  pelvic  inflammation,  the  tenderness  should  at  least  be 
partly  relieved  before  much  local  treatment  is  given,  unle.ss  dis- 
placement is  the  only  cause  of  it.     To  relieve  the  tenderness, 


282 


DISEASES    OF    WOMEN. 


treatments  given  in  the  genu-pectoral  position  by  which  the  pro- 
lapsed condition  of  the  pelvic  and  abdominal  viscera  are  at  least 
parth'  overcome,  are  the  best.  In  chronic  cases,  strengthen  the 
supports,  particularly  the  round  and  sacro-uterine  ligaments  by 
osteopathic  treatment.  This  treatment  is  directed  to  the  re- 
duction of  lesions  both  bony  and  muscular. 


Fig.  95. — Showing  uterus  forced  through  the  loop  of  the  repositor  In  replacing  re- 
troversion and  prolapsus. 

.  According  to  most  writers  all  the  uterine  ligaments  contain 
muscle  fibers,  especially  the  round  and  sacro-uterine.  Hy  re- 
storing tone  to  these  ligaments  the  uterus  will  gradually  be  drawn 
into  place.  Advise  the  patient  against  walking  or  standing  too 
much,  or  doing  any  work  whereby  strain  will  be  thrown  on  the 
abdomen,  until  after  the  uterine  supports  have  been  strengthened. 


AFFECTIONS  OF  THE  UTERUS.  283 

LATERO-FLEXION.  The  uterus  usually  lies  somewhat  to 
the  left  of  the  median  line  of  the  body.  Sometimes  by  inflam- 
mation of  one  of  the  broad  ligaments,-  cicatricial  tissue  will  be 
formed,  this  contracting  and  drawing  the  fundus  or  body  to 
that  side.  This  constitutes  latero-flexion.  It  can  readily  be 
DIAGNOSED  by  locating  the  fundus  and  cervix  by  the  bimanual 
method,  the  fundus  being  found  bent  to  one  side  or  the  other. 
On  vaginal  examination  the  broad  ligaments  on  the  affected  side 
will  be  found  tender  and  tense  and  the  fundus  can  be  felt  drawn 
to  that  side. 

LATERO-VERSION  Is  a  condition  similar  to  latero-flexion, 
but  in  addition,  the  cervix  is  drawn  to  the  opposite  side  to  that 
to  which  the  fundus  is  drawn,  and  the  uterus  lies  at  an  angle. 
It  is,  like  latero-flexion,  also  caused  by  adhesions  or  by  growths 
that  are  sometimes  found  between  the  layers  of  the  broad  liga- 
ments. No  SPECIAL  SYMPTOMS,  except  sterility,  follow  these 
lateral  displacements;  however,  there  may  be  cellulitis  or  inflam- 
mation of  the  broad  ligaments  on  the  affected  side,  such  being 
indicated  by  tenderness  and  contracture  of  the  tissues.  Latero- 
versions  can  be  readily  recognized  by  bimanual  palpation.  They 
are  treated  by  producing  absorption  of  the  inflammatory  exu- 
dates and  restoring  a  normal  circulation  to  and  through  the  broad 
ligaments.  This  is  accomplished  best  by  correcting  lesions  of 
the  innominate  on  the  same  side,  and  by  local  treatments  directed 
to  restore  normal  position  and  mobility  to  the  uterus. 

There  are  various  uterine  displacements  that  are  not 
tj'pical;  that  is,  there  is  a  combination  of  two  or  more  displace- 
ments. Often  a  case  is  found  in  which  the  uterus  has  slipped 
BACKWARD,  the  utcrine  axis  is  unchanged,  but  the  cervix  is  com- 
pressing the  rectum.  Again  the  uterus  may  be  retro  verted  against 
the  sacrum,  yet  there  is  a  curve  in  the  uterus  making  it  a  slight 


284  DISEASES    OF    WOMEN. 

anteflexion.  In  such  cases  the  uterus  seems  to  be  moulded  to 
the  anterior  surface  of  the  sacrum. 

Ascent  of  the  uterus  occurs  in  some  forms  of  disease  of 
neighboring  organs  or  structures.  In  peritonitis  or  bowel  dis- 
turbances or  diseases  of  the  peritoneum,  the  uterus  is  drawn 
upward.  In  fleshy  people  the  uterus  is  often  very  high.  In 
arthritis  deformans,  the  uterus  is  often  drawn  upward.  In  a 
case  treated  by  the  author  the  uterus  could  scarcely  be  reached 
by  vaginal  examination.  Fibroid  tumors  when  large,  draw  the 
uterus  upward. 

Torsion  of  the  uterus  is  usually  not  an  independent  displace- 
ment but  one  complicating  the  more  common  uterme  deviations. 
This  displacement  is  the  result  of  the  thickening  of  the  connective 
tissue  surrounding  the  supra-vaginal  portion  of  the  uterus.  This 
thickening  follows  parametritis  on  account  of  the  inflammatory 
deposit  in  the  connective  tissue. 

The  effect  is  similar  to  that  in  lateral  deviations,  that  is  a 
sense  of  pulling  or  drawing  in  the  affected  side,  accompanied  by 
"side  ache,"  and  pain,  which  are  frequently  diagnosed  as  ovarian 
trouble.     The  treatment  is  the  same  as  in  lateral  deviations. 

COMPLICATIONS  OF  UTERINE  DISPLACEMENTS.  Nearly 
all  forms  of  displacement  set  up  an  inflammation  either  in  or 
around  the  uterine  walls.  Metritis,  cellulitis,  peritonitis,  oophor- 
itis and  salpingitis  are  the  most  frequent  complications.  In 
other  cases  these  inflammatory  conditions,  mentioned  above, 
may  be  primary  and  the  displacement  follows  from  contraction 
of  the  ligaments ;  or  perhaps  the  ligaments  may  be  left  in  an  atonic 
condition  and  the  uterus  not  being  securely  supported  becomes 
displaced.  The  more  acute  the  displacement,  that  is,  dis- 
placements resulting  from  falls  or  like  causes,  the  more  intense 
and  acute  the  complications.  The  more  gradually  the  dis- 
placement occurs,  the  less  intense  the  complications. 


AFFECTIONS  OF  THE  UTERUS.  285 

In  acute  displacements,  the  complications  are  due  to  the 
congestion  and  inflammation  m  and  around  the  uterus.  In 
gradual  displacerhents  the  complications  result  mostly  from  pres- 
sure or  traction  of  the  uterus  on  the  adnexa.  The  complica- 
tions can  seldom  be  cured,  without  correcting  the  original  disturb- 
ance BUT  ARE  OFTEN  RELIEVED. 

The  MENSTRUAL  DISORDERS  depend  upon  the  amount  of 
blood  in  the  uterus,  the  amount  of  inflammation,  the  degree  of 
contraction  or  relaxation  of  the  uterine  walls,  the  size  of  the  in- 
ternal and  the  external  ora,  and  character  of  the  expellant  forces 
of  the  uterus ;  any  or  all  of  which  may  be  affected  by  the  displace- 
ment. 

The  weakest  abdominal  or  thoracic  viscus  will  be  affected 
reflexly,  producing  a  functional  disturbance  in  that  organ. 

The  following  named  affections  constitute  a  partial  list  of 
the  complications  of  uterine  displacements: 

Eye  troubles,  pain  in  the  ear,  toothache,  migraine,  throat 
disturbances,  enlarged  thyroid  glands,  hypertrophied  tonsils; 
mammary  disturbances,  such  as  a  retracted  nipple,  lumps  in  the 
breast,  atrophy,  mastitis  and  ulceration  resembling  cancer;  pal- 
pitation of  the  heart;  stomach  disorders,  mainly  dyspepsia  and 
nausea,  liver  engorgements,  liver  spots;  cutaneous  eruptions, 
intestinal  indigestion,  enteralgia,  kidney  affection;  spinal  curva- 
ture and  irritation,  sciatica,  Mortons  toe,  or  cramping  of  toe, 
and  pain  at  knee,  foot  or  heel. 

REMEMBER  that  it  does  very  little  good  to  replace  the  dis- 
placed uterus  when  the  supports  are  soft  and  weak,  on  which 
account  one  should  first  direct  the  treatment  to  build  up  and 
STRENGTHEN  the  SUPPORTS;  that  a  VERSION  is  usually  of  sudden 
OCCURRENCE,  while  a  flexion  is  a  gradual  one;  that  temporary 
relief  can  often  be  given  by  simply  lifting  up  the  uterus;  that 


286  DISEASES    OP   WOMEN. 

in  case  of  syncope,  the  patient  can  frequently  be  aroused  by  local 
treatment  when  all  other  methods  have  failed;  that  a  chronic 
pain  below  the  waist  line,  or  headache  in  the  top  of  the  head, 
points  to  uterine  disturbances;  that  90  per  cent,  of  women,  have 
some  form  of  uterine  displacement  which  is  the  cause  of  most  of 
their  pains  and  aches.  Also  remember  that  a  fixed,  immovable, 
or  slightly  movable  uterus  is  abnormal  regardless  of  its  position ; 
that  a  uterus  that  is  very  hard  or  quite  soft  is  abnormal.  Dr.  Still 
says  that  a  uterus  is  abnormal  if  it  has  dropped  through,  or  is 
putting  traction  on,  the  various  bands  or  ligaments  that  cross 
the  pelvic  cavity  surrounding  the  uterus,  bladder  and  rectum. 
These  bands  of  which  the  broad  ligaments  form  the  greatest  part, 
constitute  the  "pelvic  "  floor.  By  lifting  the  uterus  through  the 
opening  resulting  from  a  separation  of  these  ligaments  and  fascia, 
by  means  of  the  wire  uterine  repositor,  the  symptoms  of  the  dis- 
place^ment  can  be  relieved.  In  many  cases  of  female  trouble 
with  the  usual  symptoms  of  displacement  in  which  the  uterus  is 
apparently  normal,  simply  lifting  up  the  uterus  will  usually  re- 
lieve the  pain  and  ache. 

INVERSION  OF  THE  UTERUS.  Inversion  of  the  uterus  is 
a  partial  or  complete  turning  of  the  organ  inside  out ;  so  that  the 
•endometrium,  if  inversion  is  complete,  forms  the  covering  mem- 
brane, and  the  peritoneum  the  lining  of  the  uterine  cavity.  A 
partial  inversion  is  one  in  which  some  part  of  the  uterine  wall, 
usually  the  fundus,  is  depressed  in  a  way  similar  to  a  dent  in  a 
hat.  In  complete  inversion  the  uterus  is  completely  turned 
wrong  side  out.  This  condition  is  usually  associated  with  child- 
birth as  a  cause,  but  some  times  it  results  from  other  conditions, 
such  as  senile  atrophy  of  the  uterus,  or  softening  of  the  walls  from 
■other  causes. 

Causes.     In  order  that   inversion  be  prodvice'd,  there  must 


AFFECTIONS    OF    THE    UTERUS.  287 

be   a   DILATATION"   OF  THE   UTERINE   CAVITY;  a   WEAKNESS  of  a   part 

or  all  of  the  wall  of  the  uterus,  and  some  force  must  be  exerted, 
such  as  the  abdominal  pressure  or  traction  from  below  as  in  an 
adhered  placenta  or  polypus  that  is  attached  to  the  mucous 
membrane  lining  the  upper  part  of  the  uterine  cavity. 

The  dilated  or  distended  cavity,  is  most  frequently'  found 
immediately  after  parturition,  and  being  one  of  the  most  essential 
causes,  we  find  inversion  most  frequently  occuring  at  this  time.  In 
order  for  the  cavity  to  exist  or  be  formed  j  there  must  be  a  thin 
and  weakened  condition  of  the  walls  of  the  uterus.  This  weak- 
ness follows  an  over-distention  of  the  uterine  cavity.  This  re- 
sults from  HYDROPS  amnii  or  from  twin  pregnancy,  or  is  caused 
by  some  interference  with  the  nutrition  of  the  walls.  If  there  is 
traction  from  below,  such  as  pulling  on  the  umbilical  cord  during 
the  third  stage  of  labor,  or  if  the  pressure  of  a  polypus  occurs 
while  the  walls  are  in  this  weakened  condition,  a  partial  inver- 
sion will  result.  If  there  are  violent  contractions  during  the 
third  stage  of  labor,  it  may,  like  invagination  of  the  intestines, 
force  the  fundus  down  into  the  uterine  cavity.  This  may  occur 
in  the  latter  part  of  the  second  stage  of  labor,  that  'is,  immediately 
following  the  expulsion  of  the  child. 

Frequently  it  is  caused  by  the  improper  management  of  the 
thu'd  stage  of  labor.  Injudicious  kneading  of  a  weakened, 
flabby  uterus  during  the  third  stage  of  labor,  especially  if  local- 
ized, that  is  confined  to  one  part  of  the  uterus,  will  often  cause  an 
indentation  from  unequal  contraction. 

A  short  cord  is  sometimes  the  cause  of  inversion.  A  weak^ 
ened  condition  of  the  uterine  wall  at  the  placental  site,  permits  of 
a  partial  inversion  at  that  point. 

Inversion  not  associated  with  parturition,  is  sometimes  the 
result  of  a  fibroid  tumor  forcing  in  a  weakened  wall.     A  polypus 


288 


DISEASES  OF    WOMEN. 


attached  to  the  lining  of  the  fundus  may,  by  setting  up  uterine  con- 
tractions, be  forced  downward  and  will  pull  the  uterus  with  it. 
In  cases  of  senile  atrophy  or  where  there  is  a  circumscribed  metri- 
tis, that  part  of  the  uterus  may  partially  invert.  I  have  seen 
cases  in  which  there  were  a  great  many  disturbances  at  or  follow- 
ing the  menopause,  which  were  due  to  a  partial  inversion. 


Fio.  96. — Inversion  of  the  uterus  showing  different  degrees.     (Diagrammatic.) 

The  ESSENTIAL  ELEMENT,  which  is  the  predisposing  cause  in 
inversion,  is  an  atonic  state  of  a  part  of  the  uterine  walls, 
favoring  relaxation  of  the  muscle  fibers.  This  leads  to  a  partial 
prolapse  of  a  portion  of  the  wall  and  is  associated  with  a  regular 
contraction  of  the  muscular  tissue.  The  prolapsed  portion  is 
treated  by  the  uterus  as  a  foreign  body;  it  excites  uterine  con- 
traction, which  ends  in  a  complete  or  partial  expulsion,  of  the 
prolapsed  part.     The  cause  of  this  atonic  state  of  portion  of  the 


AFFECTIONS    OF   THE    UTERUS.  289 

uterine  wall  in  chronic  cases  can  be,  in  most  instances,  traced 
back  to  a  lesion  in  the  bony  framework,  which  interferes  with  the 
nutrition  of  the  uterine  walls. 

SYMPTOMS.  In  complete  inversion,  a  tumor  is  seen  pro- 
truding from  the  vagina,  simulating  a  polypus.  There  is  hem- 
orrhage, constant  or  periodical,  bearing  down  pains  which  in- 
crease on  movement  of  the  body  and  vesical  and  rectal  disturb- 
ances. These  symptoms  vary  with  the  degree  of  inversion  and 
the  cause  of  the  trouble.  If  it  is  a  complete  inversion  following 
delivery,  all  these  symptoms  are  exaggerated  and  the  hemorrhage 
may  be  fatal,  but  if  it  is  a  chronic  case  the  reflex  pains  are  the 
principal  symptoms.  In  acute  forms,  the  patient  in  many  cases, 
collapses  from  loss  of  blood. 

If  the  PARTIAL  INVERSION  is  the  result  of  parturition,  the 
LOCHiAL  DISCHARGE  will  Continue  for  several  days,  or  even  weeks 
longer,  than  the  normal.  The  flow  will  be  abnormal  in  character 
and  quantity,  it  usually  becoming  arterial.  After-pains  are 
present  in  a  severe  form.  This  condition  exists  in  some  cases  for 
quite  awhile  after  delivery  and  occasionally  causes  a  marked 
derangement  of  the  nervous  system.  Dr.  C.  E.  Still  recently  re- 
ported to  me  a  case  of  puerperal  insanity  treated  by  him,  that 
occurred  within  a  few  weeks  after  labor.  The  usual  symptoms 
were  present,  that  is,  the  lochial  discharge  was  abnormal  and  the 
after-pains  severe.  On  local  examination  a  partial  inversion 
was  discovered.  A  large  blunt  sound  was  introduced  into  the 
uterus  by  which  the  fold  was  straightened  by  turning  the  sound 
while  IN  UTERO.  The  patient  was  immediately  relieved  and  in  a 
short  time,  (only  two  treatments  were  given)  she  became  per- 
fectly rational  and  was  soon  discharged  as  cured.  The  patient 
remained  well    when  last  heard  from,  some  months  afterwards. 

In  CHRONIC    cases  there  is  an  anemic  condition    and  reflex 

19 


290  DISEASES    OF    WOMEN. 

circulatory  disturbances  such  as  tinnitus  aurium  and  chronic 
headaches.  Menstrual  irregularities  occur  in  chronic  cases.  The 
flow  is  profuse  at  some  periods,  premature  in  others,  and  fre- 
quently there  is  marked  cramping.  The  menstrual  period  will 
often  last  a  week  or  more,  which  results  in  nervousness  and  weak- 
ness. 

DIAGNOSIS.  Inversion  following  delivery  should  be 
suspected  from  the  severe  pain,  the  hemorrhage  more  or  less  con- 
tinuous, and  the  absence  of  the  fundus  of  the  uterus  upon  the 
placing  of  the  hand  upon  the  lower  part  of  the  abdomen.  The 
diagnosis  is  made  by  seeing  the  uterus  as  a  raw  looking  tumor 
lying  between  the  labia,  with  the  large  end  the  more  prominent. 

Apart  from  obstetrical  cases  it  is  usually  very  difficult  to 
diagnose  a  slight  inversion.  In  the  ordinary  type  a  fold  can 
sometimes  be  felt  through  the  fornix  in  the  uterine  wall.'  It 
feels  as  if  the  uterus  had  settled  or  folded  down  on  itself  as  would 
an  empty  sack  if  unsupported.  In  such  cases  if  a  large  sound, 
one  as  large  as  the  index  finger,  is  introduced  and  the  fundus 
lifted  or  the  sound  rotated  as  above  suggested,  this  fold  can  be 
straightened  but  possibly  will  not  remain  normal  but  recur,  since 
the  weakened  uterine  wall  is  the  primary  cause. 

In  recent  cases,  prolapsus  is  diagnosed  from  complete  in- 
version by  locating  the  cervix  and  os  at  the  lower  end  of  the  pro- 
truding mass.  In  procidentia  the  tumor  is  narrow  at  the  base 
and  wide  at  the  upper  part,  while  in  inversion  it  is  just  the  re- 
verse. The  covering  of  the  protruding  tumor  will  assist  in  the 
diagnosis,  since  in  prolapsus  it  is  smooth  and  shiny;  in  inversion 
it  is  a  mucous  membrane  and  is  raw  and  bleeding. 

A  POLYPUS  may  protrude  and  thus  simulate  an  inversion. 
The  color,  consistency  and  mode  of  onset  help,  but  a  complete 
diagnosis  is  made  by  a  rectal  and  bimanual  examination,  this 
revealing  the  uterus  to  be  in  the  pelvic  cavity. 


AFFECTIONS  OF  THE  UTERUS.  291 

TREATMENT.  The  treatment  differs  m  the  two  forms  of  inver- 
sion. When  it  immediately  follows  childbirth  all  that  is  necessary  is 
to  replace  the  organ,  it  being  comparatively  easy  in  such  cases. 
Pressure  exerted  directly  against  the  fundus  will  usually  accom- 
plish the  re-inversion.  Sometimes  one  finger  is  placed  in  the 
rectum  in  order  to  assist  in  the  operation,  since  in  this  manner  the 
cervix  can  be  reached  and  the  os  be  helped  to  dilate.  In  irre- 
ducible cases  an  operation  is  resorted  to  by  which  the  os  is  arti- 
ficially enlarged  or  a  part  of  the  fundus  amputated. 

Following  reduction  the  uterus  should  be  made  to  contract 
in  order  to  prevent  too  much  hemorrhage.  This  is  done  by  work 
directly  over  the  uterus  through  the  abdominal  wall,  or  if  it  can 
not  be  accomplished  this  way,  an  astringent  solution  is  injected 
directly  into  the  uterine  cavity. 

In  chronic  cases  not  immediately  following  parturition,  a 
dull  blunt  sound  as  mentioned  above,  can  be  introduced  into  the 
uterus  to  push  up  the  partial  inversion.  Care  should  be  exer- 
cised in  this  or  else  the  weakened  uterine  wall  will  be  injured, 
and  also  as  large  a  sound  as  can  be  introduced  should  be  used, 
since  it  lessens  the  liability  to  injury. 

Since  these  changes  are  due  to  atrophy  and  weakening  of 
the  uterine  wall  the  treatment  should  be  directed  to  strengthen 
them  in  addition  to  replacing  the  prolapsed  condition  of  the  wall. 
When  the  inversion  is  produced  by  pressure  from  a  growth  such 
as  a  fibroid  tumor,  the  treatment  should  be  directed  to  reduce 
the  growth  or  the  pressure  exerted  by  it,  since  that  is  the  cause  of 
the  trouble.  In  cases  of  partial  inversion  that  occur  in  multi- 
para after  they  have  passed  the  menopause,  little  can  be  done  on 
account  of  the  atrophied  and  weakened  condition  of  the  uterine 
wall.  Strong  stimulating  treatment  applied  to  the  back,  to  cor- 
rect the  muscular  as  well  as  the  bony  lesions,  is  beneficial,  and  if 
the  case  is  not  one  of  too  long  standing,  or  one  in  which  the  walls 
have  not  become  verj'  much  weakened,  the  condition  can  be 
helped  jf  not  cured. 


292  DISEASES   OF   WOMEN. 


TUMORS  OF  THE  UTERUS. 


DEFINITION  AND  CLASSIFICATION.  Gould  defines  a 
tumor  as  (1)  "any  enlargement  or  swelling  of  a  part;"  (2)"a 
new  growth  not  the  result  of  inflammation  or  hyperplasia." 
The  true  tumors  are  usually  included  under  the  latter  definition. 
In  structure,  a  tumor  consists  of  tissues  which  resemble  the  normal 
tissues  of  the  body  either  in  a  mature  or  an  immature  state. 
Thus  a  tumor  may  be  composed  of  muscle  fibers,  connective 
tissues,  fat,  etc.,  or  of  cells  like  those  constituting  the  epithelium. 
They  are  homologous  when  they  resemble  or  continue  to  grow 
in  the  tissue  in  which  they  originate,  merely  displacing  the  sur- 
rounding tissue.  Such  are  usually  innocent  tumors.  The  heter- 
ologous tumors  originate  in  one  tissue,  and  retaining  the  type 
of  that  tissue,  invade  another  tissue.  They  are  generally 
malignant,  the  epithelioma  being  a  type.  Innocent  tumors  are 
usually  composed  of  a  matured  tissue  of  the  body,  while  the 
malignant  on  the  other  hand  usually  consists  of  cells  like  those  of 
the  lower  organized  or  immature  tissues. 

FIBROID  TUMORS  of  the  uterus  are  innocent  tumors  which 
occur  in  or  on  any  part  of  the  uterus,  but  are  found  most  fre- 
quently to  be  located  in  or  on  the  fundus.  In  structure,  they 
are  made  up  of  the  constituents  of  the  uterine  wall,  that  is,  con- 
nective tissue,  unstriped  muscle  fibers,  and  fibrous  tissue,  and 
should  properly  be  called  fibro-myomata.  They  also  contain 
blood  vessels,  lymphatics,  occasionally  glandular  structures  and 
possibly  nerves. 


TUMORS    OF   THE    UTERUS.  293 

The  tumors  that  are  composed  almost  entirely  of  muscular 
fibers  are  rare.  Occasionally  in  the  early  stages,  that  is  before 
the  tumor  becomes  an  inch  in  diameter,  these  fibers  predominate 
but  soon  are  displaced  by  connective  or  fibroid  tissue.  The 
INTERSTITIAL  Variety  is  always  at  first  composed  of  muscle 
fibers,  hence  are  called  myomata.  As  the  tumor  develops  the 
muscle  fibers  are  gradually  replaced  by  fibrous  tissue,  so  when  the 
tumor  becomes  as  large  as  a  croquet  ball,  it  is  almost  entirely 
fibrous  in  character.  Fibro-myomata  are  the  most  frequent  of 
uterine  growths  and  occur  most  commonly  between  the  ages  of 
thirty  and  forty-five. 

Hirst,  in  speaking  of  fibro-myoma,  says  that  it  may  be  found 
in  the  uterus  of  at  least  20  per  cent,  of  women  over  thirty-five 
years  of  age.  This  is  possibly  too  high  an  estimate  for  all  cases, 
but  probably  not  too  high  for  nullipara.  Their  growth  is  very 
slow,  the  rapidity  depending  upon  the  vessel  union  with  the 
uterus. 

Fibromata,  as  a  rule,  increase  in  size  only  during  the 
period  of  sexual  activity  and  remain  stationary  or  undergo  atrophy 
after  the  menopause.  They  seldom  if  ever  originate  in  the  uterus 
before  puberty  or  after  the  menopause.  A  case  of  a  fibroid  tumor 
in  a  lady  63  years  old  came  under  my  care.  The  tumor  was 
about  three  inches  in  diameter,  very  hard,  but  caused  little  in- 
convenience outside  of  some  pressure  disturbances.  The  uterus 
was  forced  down  almost  to  the  degree  of  procidentia.  Although 
such  displacements  are,  as  a  rule,  quite  painful,  yet  it  caused  this 
patient  but  little  trouble. 

I  have  seen  in  the  young,  localized  enlargements  in  the  lower 
part  of  the  abdomen  which  had  been  diagnosed  as  fibroid  tumors, 
but  they  turned  out  to  be  some  form  of  bowel  trouble,  such  as 
impaction,  pregnancy,  congestive  hypertrophy  of  the  uterus, 
ovarian  cyst,  or  ascites. 


294  DISEASES    OF    WOMEN. 

Fibroid  tumors  are  rarely  found  singly  in  the  uterus, 
there  usually  being  several,  which  are  irregular,  and  vary  in  size. 
As  high  as  fifty  different  tumors  have  been  found.  In  such  cases 
they  coalesce  and  form  one  irregular  conglomerate  tumor,  hard 
and  nodular  to  the  touch. 

Their  size  varies  from  that  of  a  pea,  to  that  of  a  tumor 
weighing  fifty  or  sixty  pounds,  or  even  as  high  as  one  hundred 
and  forty  five  pounds,  as  reported  by  one  author.  They  are  most 
frequently  located  in  the  posterior  wall  of  the  fundus;  less  fre- 
quently in  the  anterior  wall  and  sides.  It  is  a  common  saying 
that  a  woman  is  always  looking  for  a  tumor,  and  I  have  seen 
them  apparently  disappointed  when  told  that  they  did  not  have 
one. 

STRUCTURE.  Fibro-myomata  are  composed  of  the  same 
elements  as  the  uterine  wall,  namely,  muscle  fiber,  connective 
tissue  and  fibroid  tissue.  The  proportion  varies,  but  in  most 
cases  the  fibrous  tissue  predominates.  The  tumor  feels  hard  to 
the  touch  and  has  a  glistening  appearance  on  section.  It  is  sur- 
rounded by  a  covering  or  capsule,  thus  admitting  of  the  opera- 
ation  called  enucleation.  The  number  of  blood  vessels  pene- 
trating its  substance  depends  upon  the  amount  of  fibrous  tissue 
present,  since  the  greater  amount  of  fibrous  tissue  present  the 
fewer  vessels  and  the  less  marked  the  menstrual  disturbances. 

If  the  muscle  fibers  predominate,  the  tumor  becomes  vascu- 
lar and  grows  rapidly.  The  structures  immediately  around  the 
tumor  are  very  vascular  and  sometimes  the  engorged  vessels  can 
be  felt  through  the  abdominal  wall.  Nerves  have  been  traced 
into  the  substance  of  the  tumor,  but  there  seems  to  be  no  sensa- 
tion in  the  tumors  except  where  they  are  covered  with  a  mucous 
membrane. 

VARIETIES.     Three  varieties  of  fibroid  tumors  have  been 


TUMORS    OF   THE    UTERUS. 


295 


recognized— SUBMUCOUS  or  polypoid,  interstitial  or  intra- 
mural, and  SUBPERITONEAL.  At  first  they  are  intramural,  that  is, 
located  in  the  uterine  wall,  but  as  they  develop  they  usually  ap- 

,  ^^|U  .IS* 


Fig.  97. — Submucous  fibroid  tumor  of  uterus. 

proaeh  one  of  the  two  free  surfaces,  thus  producing  the  other  two 
forms. 

Submucous  fibroids  are  the  most  important  clinically.  On 
account  of  their  position,  nature  regards  them  as  foreign  bodies 
and  tries  to  expel  them, especially  during  menstruation  by  uterine 


296  DISEASES    OF    WOMEN. 

contraction.  This  simulates  labor  and  causes  the  most  excruciat- 
ing pain,  especially  if  the  tumor  becomes  pedunculated.  They 
lie  usually  beneath  the  mucous  membrane,  and  as  they  are  en- 
larged, project  into  the  uterine  cavit3^  When  they  hang  free 
they  are  called  fibrous  polypi.  The  uterine  contractions  ex- 
cited by  their  presence,  leads  in  some  cases,  to  pedunculation  of 


Fig,  98.— Intramural  fibroid  tumor  of  uterus. 
(1)  Uterine  cavity.    (2)  Vagina.     (3)  Urethra.    (4)  Symphysis.     (5)  Bladder. 

the  tumor  or  even  its  expulsion  from  the  uterine  cavity.  I  have 
record  o£  numerous  cases  in  which  the  osteopathic  treatment,  by 
exciting  uterine  contraction,  produced  expulsion  of  the  tumors 
belonging  to  this  class.  Again  the  hemorrhage  is  most  marked 
in  this  kind  of  fibroid  tumor  on  account  of  the  congestion  of  the 
mucous  membrane. 

The  intramural  or  interstitial  form  remains  in  the  substance 


TUMORS    OF   THE    UTERUS. 


297 


of  the  uterine  wall  and  does  not  become  pedunculated.     This 
is  the  form  in  which  the  greatest  number  is  found. 

The  subperitoneal  form  grows  outward  and  upward  into  the 
peritoneal  cavity.     It  usually  has  a  pedicle  and  upon  the  length 


Fig.  99  — Superitoueal  form  of  fibroid   tumor  on  posterior  wall. 

of  the  pedicle  depends  the  mobility  of  the  tumor.  It  may  ascend 
and  carry  the  uterus  with  it.  thus  producing  elongation  of  the 
uterine  cavity,  or  it  may  have  a  long  pedicle ,  thus  allowing  it  to 
fall  down  from  the  abdominal  into  the  pelvic  cavity,  and  produce 


298 


DISEASES    OF    WOMEN. 


pressure  symptoms.  Sometimes  the  pedicle  becomes  twisted^ 
this  producing  a  disturbance  of  the  circulation  to  the  tumor.  If 
this  occurs  gradually,  nutrition  will  be  shut  off  and  cessation  of 
growth  follow,  but  if  it  occurs  suddenly,  gangrene  of  the  tumor 
may  set  in  and  result  in  a  fatal  peritonitis.  This  form  can  be  dis- 
tinctly felt  and  clearly  outlined  through  the  abdominal  wall,^ 
after  it  has  reached  the  size  of  an  apple. 

CAUSES.  The  cause  of  fibroid  tumors  depends  upon  dis- 
turbed circulation  which  results  in  a  deposit  of  material  by  the 
blood,  from  which  new  formations  are  produced.  They  are  devel- 
oped during  the  fruitful  age  of  the  woman.  From  this  we  would 
reason  that  their  formation  is  related  in  some  way  to  the  devel- 
opment and  ACTIVITY  of  the  sexual  apparatus.  They  are 
most  commonly  found  in  the  sterile,  whether  as  a  cause  or  re- 
sult I  do  not  know.  Coitus,  masturbation,  and  ungratified 
SEXUAL  desire  are  inducive  to  uterine  and  ovarian  congestion. 
It  has  been  asserted  that  if  the  uterine  muscle  fibers  are  denied 
the  opportunity  of  physiological  hypertrophy,  which  comes 
with  pregnancy,  they  are  prone  to  become  pathologically  en- 
larged from  new  formations  in  the  musculo-fibrous  tissue  in  con- 
sequence of  the  various  sitmuli  mentioned  above. 

The  REPEATED  CONGESTION  of  the  uterus  coincident  with 
menstruation  without  any  period  of  rest,  is  a  very  probable  cause. 
Each  organ  must  have  its  period  of  rest,  and  if  this  engorgement 
of  the  uterus  is  not  relieved  by  a  physiological  process,  such  as 
pregnancy,  it  will  predispose  to  deposits  and  new  formations. 
The  function  of  the  uterus  is  to  provide  a  place  for  gestation  and 
to  furnish  nourishment  for  the  embryo  from  conception  to  end  of 
term,  and  if  this  function  is  interfered  with,  disease  especially  of 
a  tumorous  nature  is  very  likely  to  result.  Sexual  activity  and 
irritation  accompanied  by  the  use  of  means  to  prevent  conception,. 


TUAIORS    OF   THE    UTERUS.  299 

are  certainly  important  causes.  It  has  been  noted  by  the  author 
and  others  that  in  typical  cases  of  fibroid  tumors  there  was  an 

INTENSE   DESIRE   UPON  THE   PART   OF    THE   WOMAN  FOR   CHILDREN. 

This  is  true  of  the  unmarried  nullipara,  as  well  as  the  married. 
This  condition  leads  to  repeated  pelvic  engorgements  which  are 
necessary  in  the  production  of  tumors. 

In  looking  over  the  record  of  cases  that  I  have  treated,  I  find 
that  in  most  cases  there  was  a  subluxated  innominate,  or  a  rigid 
spinal  column  in  the  lumbar  region,  or  both  of  these  conditions 
were  present.  If  the  symphysis  is  carefully  examined,  tender- 
ness and  irregularities  will  be  discovered,  which  are  indicative  of 
an  innominate  lesion.  The  vaso-motor  centers  controlling 
the  uterine  circulation  are  in  the  lumbar  spinal  cord  and  a  rigid 
spine,  or  a  posterior  curvature  occuring  in  this  region,  will  affect 
these  centers.  This  keeps  up  a  constant  irritation  of  the  uterus, 
which,  like  the  bruise  of  the  bark  of  a  cherry  tree,  terminates 
in  an  exudate  or  deposit.  The  blood  supply  is  deranged.  Blood 
that  is  formed  for  another  part  of  the  body  is  possibly  switched 
off  and  its  contents  deposited  in  the  vascular  uterus.  Each  part 
of  the  body  has  blood  formed  especially  for  it,  and  it  seems  reason- 
able to  me  that  if  blood  carrying  food  that  was  not  intended  for 
the  uterus,  should  get  into  the  uterus,  its  load  would  be  deposited 
after  repeated  attempts  to  escape,  regardless  of  the  so-called 
selective  function  which  each  tissue  is  supposed  to  have.  If 
the  patient  first  has  these  bony  lesions,  then  the  causes  above 
mentioned  may  the  more  readily  act.  If  the  first  of  the  above 
mentioned  causes  were  true,  why  does  not  every  sterile  woman 
between  the  age  of  thirty  and  fortj^-five,  have  a  fibroid  tumor? 
I  know  FROM  experience  that  these  lesions  are  the  most 
IMPORTANT  AS'^  CAUSATIVE  FACTORS,  bocause  I  have  cured  cases 
by   correcting  these  lesions. 


300  DISEASES    OF    WOMEN. 

Another  explanation  lies  in  the  fact  as  stated  above,  that  the 
CENTERS  for  the  TONE  and  nutrition  of  the  uterine   muscle 

FIBERS  ARE  IN  THE  ANTERIOR  HORNS  OF  THE  GREY  MATTER  OF  THE 

LUMBAR  SPINAL  CORD.     If  the  cells  in   these   horns   are   made   to 
act  abnormally  there  will  be  an  effect  in  the  parts  supplied.     A 

RIGID  LUMBAR  SPINE  will  affect  the  ACTIVITY  of  the  CELLS  by  IN- 
TERFERING WITH  THEIR  NUTRITION.  Myoma,  reasoning  from 
the  above,  would  be  the  primary  tumor  formed.  The  rigidity  of 
the  lumbar  spine  results  from  occupation  wherein  the  patient 
is  on  her  feet  a  great  deal. 

The  discs  flatten  and  lose  their  elasticity.  The  vertebrae 
are  thereby  approximated,  which  condition  necessarily  lessens 
the  size  of  the  intervertebral  foramina.  The  structures  passing 
through  these  foramina  would  then  be  affected  in  some  way. 

A  displaced  uterus  is  frequently  a  forerunner  of  fibroid  tumors. 
The  formation  of  some  of  these  tumors  can  be  traced  back  to  a 
fall  or  heavy  lift,  but  this  has  particular  reference  to  those  of 
quick  formation. 

I  sometimes  compare  their  formation  to  an  excresence  on  an 
oak  or  an  exudate  on  a  cherry  or  peach  tree.  There  must  have 
existed  some  disturbance  to  the  supply  of  nutrition  to  that  part 
from  some  sort  of  injury.  The  circulation  of  the  sap  must  have 
been  disturbed  in  some  way.  So  it  is  with  a  foreign  growth  on 
the  uterus.  It  is  a  result  of  a  disturbance  to  the  circulation,  an 
irritation  somewhere,  and  this  disturbance  is  in  most  cases  the 
result  of  a  bony  lesion  in  the  above  mentioned  places,  a  uterine 
displacement  or  an  injury  to  it  from  the  improper  use  of  a  sound 
or  other  instrument. 

General  weakness,  which  implies  local  weakness,  has  been 
mentioned  as  a  possible  cause  of  fibroids.  This,  physicians  have 
attempted  to  overcome  by  the  administration  of  a  diet  composed 
largely  of  meats. 


TUMORS    OF   THE    UTERUS.  301 

The  "Old  Doctor"  has  often  remarked  that  it  was  very  un- 
usual for  a  FOUR  FOOTED  ANIMAL  to  have  a  fibroid  tumor.  After 
examining  a  great  number  of  animals  and  not  finding  any  indica- 
tions of  fibroids,  he  came  to  the  conclusion  that  tumors  were  part- 
ly due  to  the  position  of  the  animal.  This  position  prevented 
enteroptosis  or  a  packing  of  the  pelvic  cavity  with  intestines  .In 
women,  the  upright  position  tends  to  produce  enteroptosis.  This 
is  counteracted  in  part  by  the  mesentery  and  the  abdominal  wall. 
The  abdominal  walls  are  weakened  by  the  character  of  the  dress, 
that  is,  its  function  is  subserved  by  the  tight  dress,  and  when  the 
function  of  a  muscle  is  suspended,  it  atrophies.  Thus  it  is  in 
the  case  of  the  abdominal  muscles,  atrophy  follows  and  then 
comes  enteroptosis.  This*  results  in  a  packed  and  congested 
pelvis.  A  deposit  mvist  follow  and  finally  a  tumor  forms.  I  be- 
lieve that  enteroptosis  exists  in  ninety  per  cent,  of  all 
cases  of  fibroid  tumors.  Incidentally  the  remark  might  be 
made,  that  if  the  patient  would  walk  on  all  fours  for  a  period  of 
time  a  cure,  unless  the  disease  had  progressed  too  far,  would  fol- 
low. 

SYMPTOMS.  Fibroid  tumors,  like  other  pathological 
growths  of  the  uterus,  usually  produce  no  symptoms  until  they 
are  quite  well  developed.  A  great  many  people  do  not  know 
that  they  have  a  tumor  until  told  so  by  their  physician,  since  if 
the  tumor  is  small,  there  are  very  few  noticeable  symptoms.  The 
most  important  is  that  of  hemorrhage.  This  comes  on  gradual- 
ly, instead  of  suddenly  as  in  cancer  of  the  uterus,  at  first,  as  an 
increase  of  the  menstrual  flow,  which  .is  called  menorraghia. 
After  a  time  this  may  amount  to  a  flooding  or  there  may  be  irregu- 
lar hemorrhages  or  metrorrhagia.  The  size  of  the  tumor,  un- 
less it  is  too  fibrous,  increases  just  immediately  before  and  during 
menstruation.     The  amount  of  increase  in  size  is  quite  indicative 


302  DISEASES    OF    WOMEN. 

of  the  degree  of  menorrhagia.  This  hemorrhage  does  not  come 
from  the  tumor,  but  from  the  thickened  mucous  membrane  lining 
the  uterine  cavity.  In  some  cases  the  loss  of  blood  threatens  the 
patient's  life.  The  writer  saw  a  case  recently  in  which  there  had 
been  flooding  for  over  a  week.  The  patient  was  anemic,  ears  and 
lips  colorless,  pulse  rapid  and  weak  and  there  was  a  condition  of 
almost  complete  syncope. 

The  HEMORRHAGE  is  uot  SO  marked  in  the  subperitoneal  form 
as  in  the  other  types  of  fibroid  tumors,  but  there  is  usually  some 
increase  in  amount  of  menstrual  discharge.  In  the  mucous 
form,  the  hemorrhage  is  greatest  and  threatens  the  patient's 
life  on  account  of  loss  of  blood.  Leucorrhea  often  appears  in 
the  inter-menstrual  period  on  account  of  the  pelvic  congestion. 

Pain  is  present  in  the  form  of  a  backache  or  dysmenorrhea. 
If  it  is  a  submucous  form  of  tumor,  the  pain  will  resemble  labor 
pain,  since  the  uterus  is  contracting  in  its  effort  to  expel  the  for- 
eign body,  which  is,  in  this  case,  the  tumor.  The  pain  is  brought 
on  by  the  tumor  becoming  pedunculated,  the  pressure  on  the 
cervix  exerted  by  it  causes  impulses  to  be  generated  which  bring 
on  the  uterine  contractions.  It  is  very  similar  to  labor.  A  body 
to  be  expelled,  an  obstruction  to  overcome,  and  a  force  with 
which  to  expel.  The  same  mechanism  is  at  work  as  in  normal 
labor  and  the  suffering  is  often  a  great  deal  worse. 

The  backache  is  found  most  often  in  the  upper  portion  of 
the  sacrum  and  lower  lumbar  region.  The  increased  weight  of  the 
uterus  causes  a  sensation  of  discomfort,  which  is  described  as  a 
fullness  or  weight  in  the  pelvis,  or  a  "dragging  down"  sensation. 
This  pressure  on  the  nerves  produces  pains  in  the  limbs,  sometimes 
sharp  or  shooting,  sometimes  that  of  weight  or  pressure.  Traction 
on  the  various  ligaments  produced  by  the  increased  weight  of  the 
tumor,  causes  the  backache,  which  is  almost  unbearable  in  some 
cases. 


TUMORS    OF   THE    UTERUS.  303 

Pressure  on  the  bladder  causes  frequent  micturition. 
Pressure  on  the  neck  of  the  bladder  may  produce  symptoms  of 
cystitis,  indirectly  caused  by  the  retention  of  the  urine.  Pres- 
sure on  the  adjacent  vessels  produces  hemorrhoids  and  vari- 
cose veins  of  the  limbs.  Pressure  on  the  rectum,  produces 
tenesmus,  constipation,  or  a  diarrhea  if  there  is  a  congestion  of 
the  mucous  membrane  of  the  bowels.  Pressure  on  the  ureters 
leads  to  kidney  trouble,  such  as  hydronephrosis  or  albuminuria. 
Pressure  on  the  uterus  results  in  displacement,  this  being  in  the 
direction  of  least  resistance.  Sterility  is  usually  present, 
sometimes  as  a  cause,  sometimes  as  a  symptom.  Abortion  may 
be  induced  by  the  presence  of  the  tumor  and  labor  at  term  ser- 
iously complicated,  either  as  a  result  of  the  mechanical  obstruc- 
tion or  post-partum  hemorrhage. 

PHYSICAL  SIGNS.  In  the  case  of  large  tumors,  no  diffi- 
culty will  present  itself  in  making  a  correct  diagnosis,  since 
the  results  obtained  by  inspection,  vaginal  examination,  abdominal 
palpation  and  conjoined  manipulation  will  be  so  decided,  that 
they  will  definitely  settle  the  character  of  the  case.  Inspection 
will  show  enlargement  of  the  abdomen;  this  not  being  symmetri- 
cal in  a  majority  of  cases.  Abdominal  palpation  in  a  typical 
case  discloses  a  large,  hard,  solid  mass,  though  in  exceptional 
cases  it  may  be  soft.  Sometimes  this  tumefaction  may  closely 
resemble  pregnancy,  but  there  will  be  the  absence  of  the  usual 
indications  of  pregnancy.  In  cases  of  pregnancy  in  which  the 
abdomen  is  very  much  enlarged,  quickening  and  the  fetal 
HEART  beat  can  be  elicited,  thus  diagnosing  the  case.  If  irregular 
hard  lumps  are  found  it  is  a  good  diagnostic  sign  of  fibroid  tumors. 
In  the  vaginal  examination  the  tumor,  if  on  the  anterior  wall, 
can  be  felt  through  the  anterior  fornix  as  a  hard  irregular  mass. 
This  enlargement  is  diagnosed  from  the  fundus  by  locating  the 


304  DISEASES    OF    AVOMEN. 

fundus  in  some  other  part  of  the  pelvis;  also  it  is  harder  and  is 
accompanied  by  menstrual  disturbances  such  as  menorrhagia. 
If  the  tumor  is  on  the  posterior  wall  it  can  be  felt  in  the  pos- 
terior fornix  or  be  outlined  by  rectal  examination.  By  using  the 
bimanual  method,  the  size,  location  and  density  of  the  tumor 
can  be  learned.  The  uterine  canal  is  elongated,  which  can  be 
learned  by  the  use  of  a  sound.  This  is  not  to  be  recommended  on 
account  of  the  danger  of  bringing  on  an  inflammation  or  hem- 
orrhage. The  external  os  is  enlarged,  sometimes  patulous,  and 
the  cervix  softened.  In  other  cases  the  cervix  is  rim  like,  and  the 
walls  quite  thin.  The  entire  uterus  is  found  prolapsed  in  the 
typical  case,  but  in  large  tumors  and  unusual  cases,  there  is 
ascent. 

DIFFERENTIAL  DIAGNOSIS.  A  very  large  fibroid  tumor 
may  be  mistaken  for  pregnancy.  It  can  be  diagnosed  from 
normal  pregnancy  by  the  absence  of  the  usual  indications 
OF  pregnancy.  In  extra-uterine  forms  of  pregnancy  the  diag- 
nosis is  more  difficult.  The  character  of  the  enlargement,  his- 
tory, growth  and  symptoms  must  be  considered.  In  both  extra- 
uterine pregnancy  and  fibroids,  there  is  hemorrhage  and  both 
form  a  mass  about  or  near  the  uterus.  In  tubal  gestation  the 
tumor  is  quite  sensitive  with  colicky  pains  occuring  at  irregu- 
lar intervals.  Fibroids  are  not  tender,  and  except  in  the  sub- 
mucous type,  there  are  no  colicky  pains.  When  rupture  of  the 
sac  in  ectopic  pregnancy  takes  place,  there  are  intense  lancinat- 
ing pains  and  severe  shock.  In  fibroids  the  pain  is  a  pressure  one, 
hence  not  lancinating,  but  constant  and  aching. 

In  normal  pregnancy  the  enlargement  at  first  is  symmetri- 
cal, the  OS  patulous  and  the  cervix  soft.  Amenorrhea  is  pres- 
ent instead  of  menorrhagia,  as  in  fibroids.  In  fibroids  the  en- 
largement is  frequently  irregular,  and  os  not  necessarily  patU' 


TUMORS    OF   THE    UTERUS.  305 

loiis  unless  there  is  a  great  deal  of  inflammation  and  the  growth 
very  slow.  If  there  is  any  doubt  as  to  whether  the  case  is  one  of 
pregnancy  or  fibroid  tumor,  wait;  a  few  months  will  tell.  At 
LEAST  AVOID  RADICAL  TREATMENT.  Mistakes  in  diagnosis  have 
been  made,  are  being  made,  and  will  be  made  as  long  as  there  are 
physicians  and  patients,  unless  care  is  exercised. 

The  fibroid  tumor  is  diagnosed  from  a  displacement  op 
THE  UTERUS,  such  as  a  flexion,  by  its  size,  consistency,  it  being 
more  dense,  by  its  irregularity  and  by  finding  the  fundus  by  the 
bimanual  method.  It  is  diagnosed  from  cancer  by  the  age,  it 
appearing  before  the  menopause,  absence  of  laceration,  this  being 
a  common  cause  of  cancer;  absence  of  odor,  a  slower  hemorrhage, 
it  being  sudden  in  cancer,  absence  of  constitutional  symptoms 
such  as  emaciation  and  the  cancerous  cachexia  and  the  character 
of  discharge,  it  being  first  of  a  watery,  then  of  a  purulent  nature 
in  cancer.  Sometimes  in  an  incarcerated  polypus  or  one  in  which 
the  pedicle  has  been  suddenly  twisted,  there  will  be  some  of  the 
symptoms  of  cancer,  but  can  be  diagnosed  by  locating  the  tumor 
and  noting  its  size,  shape  and  consistency. 

An  impacted  bowel  may  be  mistaken  for  a  tumor,  but  this 
should  not  occur  if  the  symptoms  of  an  impaction  are  remembered 
and  the  shape,  size  and  consistency  of  the  tumor  be  noticed.  A 
case  of  fibroid  tumor  was  recently  brought  to  the  A.  T.  Still  In- 
firmary which  had  been  diagnosed  as  an  impaction,  and  the  pa- 
tient had  exhausted  the  supply  of  purgatives  which  had  been 
prescribed  by  the  regular  physicians.  The  pressure  of  the  tumor 
produced  constipation  and  impaction,  and  the  cause  was  over- 
looked on  account  of  the  symptoms. 

A  PARTIALLY  INVERTED  uterus  may  at  first  be  diagnosed  as 
a  pedunculated  fibroid,  but  the  history,  symptoms,  absence  of 
the  fundus  of  the  uterus  in  the  pelvic  cavity,  felt  as  a  round,  not 

20 


306  DISEASES    OF    WOMEN. 

as  an  indented  body  as  ascertained  by  abdominal  examination, 
will  clear  up  the  diagnosis.  An  ovarian  or  uterine  cyst  is  rec- 
ognized by  the  fluctuation,  softness  of  the  tumor,  rapid  growth  and 
absence  of  arterial  hemorrhage  during  menstruation. 

PROGNOSIS.  The  prognosis  as  to  a  cure,  depends  upon  the 
LENGTH  of  standing  of  the  case,  degree  of  density  and  size  of 
tumor,  mode  of  onset,  age  of  patient,  and  the  lesions  found.  If 
the  case  is  of  short  duration,  and  is  not  op  a  fixed  size,  that  is  if 
it  gets  softer  and  larger  at  times,  prognosis  is  favorable. 
If  it  is  a  solid  tumor  of  slow  growth  the  size  of  a  croquet  ball, 
the  prognosis  is  unfavorable.  If  the  onset  is  sudden,  and  tumor 
is  of  rapid  growth  and  soft  and  the  patient  is  near  the  menopause 
the  prognosis  is  more  favorable.  If  a  marked  lesion  is  found 
and  the  case  of  not  too  long  standing,  a  cure  is  probable.  I  have 
taken  cases  in  the  early  stages  of  the  growth  and  have  stopped 
the  progress  and  in  some  cases  have  even  cured  them.  If  the 
patient  is  near  the  menopause  the  prognosis  is  favorable  regard- 
less of  the  character  of  the  tumor  since  "in  a  great  many  cases  it 
undergoes  spontaneous  absorption  at  that  time.  If  it  occurs 
during  gestation  it  grows  very  rapidly  on  account  of  the  in- 
creased vascularity  and  in  some  cases  it  will  undergo  atrophy 
during  involution  of  the  uterus.  They  seldom  end  fatally  but 
are  very  chronic,  causing  the  patient  to  suffer,  at  least  until  the 
menopause  is  reached. 

The  prognosis,  as  to  relieving  the  symptoms,  is  favor- 
able. By  osteopathic  treatment  the  pressure  symptoms,  hem- 
orrhage and  the  various  aches  can  be  lessened  unless  the  case  is 
a  very  unusual  one. 

TREATMENT.  The  question  is  often  asked  whether  a 
fibroid  tumor  can  be  cured  by  osteopathic  treatment.  I  will 
answer  by  giving  results  of  some  cases  treated  at  the  A.  T.  Still 


TUMORS    OF   THE    UTERUS.  307 

Infirmary.  Cases  of  short  duration  and  tumors  that  were  soft 
and  not  very  large,  have  either  been  cured,  or  the  progress 
of  their  growth  stopped  in  every  case  that  I  have  seen  in  which 
the  patient  allowed  us  at  least  six  months  treatment.  In 
cases  in  which  there  was  a  great  deal  of  fibrous  tissue,  of 
LONG  standing  and  necessarily  very  hard,  and  as  large  as  the 
two  fists,  personally,  I  have  not  seen  one  in  which  the  tumor 
was  absorbed,  but  in  most  cases  the  symptoms  were  wholly  or 
partially  relieved.  Dr.  C.  E.  Still,  who  has  treated  more  cases 
of  fibroid  tumors  than  any  other  osteopathic  physician,  reports 
cures  in  many  of  the  above  described  cases.  He  usually  insists 
upon  the  patient  remaining  under  his  care  for  one  year  before 
he  consents  to  take  the  case  and  promise  much.  Very  few  cases 
respond  readily,  that  is,  few  changes  occur  in  a  few  months  treat- 
ment and  the  patient  often  becomes  discouraged  at  the  end  of 
that  time  and  gives  up  the  treatment,  saying  that  osteopathy  is 
a  failure;  whereas  if  they  had  continued  under  treatment 

FOR   A  LONGER   TIME  SOME    CHANGE  FOR   THE   BETTER  WOULD  HAVE 

been  noted.  Goodall  says  that  "solid  uterine  fibroids  of  a  stony 
hardness  of  several  pounds  weight  will  occasionally  disappear," 
and  he  cites  forty  cases  in  support  of  his  statement. 

Emmett  also  reports  similar  cases  of  spontaneous  absorp- 
tion. If  such  results  occur  spontaneously,  why  will  they  not 
occur  oftener  and  more  rapidly  under  osteopathic  treatment, 
which  is  one  of  adjustment,  hence  helpful  to  the  natural  forces. 
I  firmly  believe  that  in  the  cases  in  which  there  is  a  failure, 
the  fault  is  usually  with  the  physician,  and  that  we  lack  the 
requisite  skill  in  cases  in  which  we  fail.  Osteopathy,  if 
properly  applied,  will  cure  any  case  of  tumor  that  is  curable. 
In  the  CURATIVE  treatment  the  bony  lesions  that  are  found, 
are  corrected.     This  is  the  fundamental  and  primary  step.     By 


308  DISEASES    OF    WOMEN. 

the  correction  of  these  lesions  that  disturb  the  circulation,  the 
nutrition  to  the  uterus  is  re-established  and  that  of  the  tumor  is 
shut  off  and  soon  absorption  begins.  It  can  be  compared  to  the 
treatment  of  a  goiter  or  an  enlarged  tonsil.  The  absorption 
follows  the  correction  of  the  lesion  unless  there  is  too  much  fi- 
brous tissue  already  formed,  which  is  very  slow  of  absorption. 
The  question  arises,  is  the  absorption  produced  by  increasing 
the  arterial  blood  supply  or  lessening  it?  I  think  it  is  produced 
by  restoring  a  normal  circulation  of  blood  to  and  from  the  organ. 
Since  nature  tends  toward  the  normal,  any  little  help  that  can 
be  given,  increases  the  power  of  nature  to  throw  off  foreign  ele- 
ments and  restore  the  natural  circulation  to  and  around  the 
part.  As  mentioned  before,  if  this  disturbing  factor,  the  lesion, 
BE  CORRECTED,  nature,  unless  the  process  has  gone  too  far,  will 
CERTAINLY  ASSERT  HERSELF  and  restore  the  parts  to  their  normal 
condition.  In  addition,  the  tumor  should  be  loosened  and  soft- 
ened by  lifting,  or  pushing  it  out  of  the  pelvis,  in  order  to  free 
the  circulation.  This  can  be  done  by  working  directly  over  the 
tumor  through  the  abdomen  or  by  the  use  of  Dr.  Still's  wire  re- 
positor.  By  doing  this  every  few  days  the  tumor,  after  awhile, 
becomes  softened,  pressure  on  the  blood  vessels  and  other  neigh- 
boring structures  relieved,  and  absorption  is  increased. 

I  do  not  mean  by  this  that  the  tumor  should  be  massaged. 
On  the  other  hand  I  think  massage  is  contraindicated.  The 
abdominal  treatment  should  be  confined  to  a  lifting  up  one, 
which  tends  to  relieve  the  pressure  and  free  the  circulation.  The 
local  application  of  drugs  will  not  do  this,  nor  will  the  internal 
administration  of  same  do  any  good. 

The  IDEAL  way  of  treating  fibroids  according  to  the  author's 
notion,  based  upon  enteroptosis  as  the  most  important  of  the 
causes,  is  to  put  the  patient  to  bed  and  keep  her  there  for 


TUMORS    OF   THE    UTERUS.  309 

SEVERAL  MONTHS,  the  length  of  time  depending  on  the  size  and 
density  of  the  tumor.  The  prone  posture  relieves  pelvic  con- 
gestion,   which   UNDOUBTEDLY   IS   THE    IMPORTANT,    IMMEDIATE   Or 

exciting  cause  of  tumors.  Coupling  with  the  rest  treatment, 
an  ABDOMINAL  ONE,  directed  to  the  relieving  of  the  impacted 
pelvis  and  one  directed  at  the  correction  of  the  spinal  lesions, 
a  cure  would  seem  more  probable  than  under  the  ordinary  cir- 
cumstances. 

Since  the  above  treatment  in  the  average  case  is  out  of  the 
question,  the  wearing  of  a  support  is  to  be  advised,  if  the 
tumor  is  very  large  and  heavy.  "The  Old  Doctor"  has  devised 
a  belt  so  arranged  that  if  properly  applied,  the  enteroptosis  can 
be  considerably  relieved,  thus  improving  pelvic  circulation. 

In  cases  of  extreme  backache  accompanying  the  tumor, 
pressure  over  the  perineum  with  the  palm  of  the  hand,  will 
temporarily  relieve  the  pain.  The  patient  should  be  kept 
from  standing,  or  walking  very  much,  since  this  increases 
the  pressure  or  tension,  thus  making  the  condition  worse.  Every- 
thing THAT   produces   PELVIC   CONGESTION  SHOULD   BE   AVOIDED 

if  possible  to  do  so.  Constipation,  coitus,  tight  clothing,  stand- 
ing on  the  feet  for  several  consecutive  hours,  walking  or  vigorously 
using  the  limbs  in  any  way,  such  as  running  a  sewing  machine, 
all  tend  to  exaggerate  the  already  existing  pelvic  congestion. 
Especially  at  the  menstrual  period  should  the  above  mentioned 
things  be  avoided,  and  if  possible  keep  the  patient  in  a  reclining 
posture.  The  knee-chest  position  should  be  assumed  quite  often, 
since  this  relieves  in  part  at  least,  the  congestion  of  the  pelvic 
viscera. 

In  cases  of  menorrhagia  in  which  the  flow  is  arterial  in 
character,  the  patient  should  be  put  to  bed  with  the  foot  of  the 
bed  elevated,  and  treatment  given  to  contract  the  uterus.     This 


310  DISEASES    OF    WOMEN. 

is  ordinarily  accomplished  by  strong  stimulation  over  the  lower 
lumbar  region  and  clitoris.  Hot  injections,  ice  packs  or  as- 
tringent solutions  of  sulphate  of  iron,  alum  or  witch  hazel,  can 
be  introduced  directly  into  the  uterine  cavity,  when  the  other 
methods  fail.  On  account  of  its  action  on  the  smaller  blood 
vessels  their  use  seldom  fails  to  stop  or  check  the  hemorrhage. 
The  custom  of  packing  the  vagina  is  not  very  successful,  it  only 
results  in  preventing  external  hemorrhage  while  often  the  in- 
ternal, still  continues. 

OPERATIONS.  About  the  first  thing  that  a  surgeon  ad- 
vises in  the  case  of  a  fibroid  tumor,  is  an  operation,  and  I  think 
many  lives  have  been  sacrificed  on  account  of  a  too  free  use  of 
the  knife.  I  know  of  a  great  many  cases  in  which  hysterectomy 
was  performed  by  eminent  surgeons  for  a  very  small  fibroid 
that  was  causing  very  little  inconvenience.  In  a  large  per  cent, 
of  these  cases  the  operations  were  successful,  but  the  patient  died. 
Why  risk  a  patient's  life  by  operations  when  the  symptoms 
are  not  severe  nor  point  to  a  fatal  termination? 

The  osteopath  believes  in  surgery;  it  is  a  distinct  separate 
science,  but  it  should  be  a  last  resort  after  other  methods  have 
failed.  Operations  for  the  removal  of  fibroid  tumors  are  rec- 
ommended if  the  case  can  not  be  cured  by  osteopathic  treat- 
ment, after  a  fair  trial  has  been  given.  If  the  symptoms  are 
severe  enough  and  cause  the  patient  constant  pain,  or  if.  the  pa- 
tient is  not  near  the  menopause  an  operation  is  usually  advisable. 
They  are  not  advised  if  the  tumor  is  small,  and  the  symptoms 
mild,  or  if  the  patient  is  near  the  menopause,  for  in  the  majority 
of  cases  the  growth  will  stop  or  the  tumor  will  undergo  atrophy 
at  that  time.  For  the  different  kinds  of  operations,  and  the 
methods  used,  a  work  on  surgical  gynecology  should  be  con- 
sulted. 


/ 

TUMORS   OF   THE   UTERUS.  311 

Curettage  is  sometimes  performed  by  surgeons  in  cases  of 
the  submucous  form  of  fibroid  tumors,  by  means  of  the  sharp 
curette  as  shown  in  Fig.  100.     In  this  way  the  lining  membrane  of 


Fig.  100. — The  sharp  uterine  curette. 

the  uterus  with  a  part  of  the  tumors  are  removed.  This  should 
NOT  BE  RESORTED  to  Until  Osteopathic  treatment  has  failed,  on 
account  of  the  hemorrhage,  danger  of  infection,  and  on  account 
of  the  small  amount  of  relief  that  usually  follows  the  operation. 

In  other  types  of  fibroids,  although  marked  hemorrhage 
exists,  curettage  is  of  no  value.  A  great  many  cases  of  sub- 
mucous fibroids  have  been  reported  me  as  cured  by  the  ordinary 
osteopathic  treatment. 

The  use  of  electricity  is  advised  by  some.  Hirst  says 
that  he  was  appointed  by  the  Philadelphia  County  Medical 
Society,  as  one  of  a  committee  of  three  "to  investigate  this  form 
of  treatment  for  fibroids."  He  says  "In  three  years  time  not 
a  single  case  was  presented  of  a  tumor  reduced  in  size  by  elec- 
trical treatment."  If  beneficial  at  all  it  is  only  palliative;  such 
a  treatment  does  not  remove  causes.  A  perverted  condition 
of  the  structures  of  a  part  of  the  body  exists,  which  must  be 
corrected  before  a  cure  is  completed. 

POLYPI.  A  polypus  is  a  pedunculated  tumor  attached  to 
a  mucous  membrane.  Those  found  in  the  uterus  are  of  the 
mucous  or  fibroid  variety,  the  latter  being  the  more  common. 
The  FIBROUS  POLYPI  spring  from  the  muscular  wall  of  the  uterus, 
most  commonly  from  the  body  since  that  is  the  usual  seat  of 
fibroid  tumors.  They  are  similar  to  fibroid  tumors  as  to  con- 
sistency, appearance  and  structure;  in  fact  they  are  fibroid  tu- 


312 


DISEASES    OF   WOMEN. 


mors  with  a  pedicle.  In  size  they  vary  from  that  of  the  end  of 
the  finger  to  that  of  a  goose  egg  or  even  larger.  As  they  en- 
large the  uterine  cavity  is  dOated  and  the  pressure  exerted  on 
the  cervix  sets  up  uterine  contractions  which,  in  a  great  many 
cases  cause  their  expulsion.  They  are  sparingly  vascular  but 
are  congested  and  enlarged  during  menstruation.  This  en- 
largement increases  the   uterine  contraction  and  is  a  favorable 


Fig.  101. — Different  forms  of  uterine  polypi,  with  the  vagina 
and  part  of  the  cervix  removed. 


time  for  their  expulsion  on  account  of  the  dilated  condition  of 
the  OS  uteri.  After  it  has  been  expelled  from  the  uterus,  it  still 
retains  connection  with  the  uterus  by  a  long  pedicle. 

A  mucous  polypus  is   soft  and  pulpy  and  rarely  reaches  a 


TUMORS    OF    THE    UTERUS.  313 

size  larger  than  that  of  an  almond.  They  are  developed  from 
the  mucous  membrane  lining  the  cervix  and  usually  appear  in 
groups.  They  are  extremely  vascular  and  bleed  readily  on  irri- 
tation. 

SYMPTOMS.  Hemorrhages  are  the  first  symptoms  on 
account  of  the  location  of  the  tumor,  it  being  on  or  near  the 
mucous  membrane.  It  like  hemorrhage  from  fibroid  tumors, 
begins  as  a  menorrhagia,  but  afterward  it  becomes  irregular  and 
assumes  the  form  of  metrorrhagia.  It  comes  from  the  con- 
gested mucous  membrane  and  from  the  polypus  itself. 

Leucorrhea  is  present  as  a  result  of  the  congestion  of  the 
endometrium.  Dysmenorrhea  is  very  marked  in  cases  in  which 
the  polypi  cause  pressure  on  the  cervix.  It  is  similar  to,  or 
even  worse  in  some  cases,  than  parturition.  In  other  cases 
the  presence  of  a  polypus  has  caused  various  reflex  symptoms 
of  pregnancy,  such  as  pigmentation  of  the  breast  and  morning 
sickness.  Sterility  is  caused  partly  by  the  obstruction  pro- 
duced by  the  polypus  and  partly  by  the  diseased  condition  of 
the  endometrium  which  accompanies  these  cases;  this  not  per- 
mitting of  a  secure  attachment  of  the  ovum  to  the  uterine  wall. 

DIAGNOSIS.  If  the  external  os  is  so  dilated  that  the  tu- 
mor protrudes  into  the  vagina,  it  can  be  recognized  by  the  finger 
on  vaginal  examination  or  by  inspection,  a  speculum  being  used. 
Then  by  encircling  the  cervix  with  the  finger  and  examining  the 
body  through  the  fornices  the  pedicle,  and  the  size  of  the  tumor 
can  be  readily  ascertained.  By  the  use  of  a  speculum,  the  tu- 
mor will  appear  of  a  bright  color,  which  contrasts  with  the  dark 
red  color  of  the  cervical  mucous  membrane.  Sometimes  it  is 
advisable  to  introduce  the  finger  directly  into  the  uterus,  thus 
exploring  the  uterine  cavity,  the  polypus  then  can  be  plainly 
felt,  making  the  diagnosis  certain. 


314  DISEASES    OF   WOMEN. 

The  polypus  may  be  mistaken  for  a  partial  inversion  es- 
pecially if  very  much  hemorrhage  is  present.  The  presence  of 
the  fundus  in  the  pelvic  cavity  as  ascertained  by  bimanual  pal- 
pa'tion,  the  slowness  of  the  onset,  the  consistency  of  the  tumor, 
it  being  harder,  and  the  shape  and  appearance  of  the  polypus 
are  sufficient  to  diagnose  a  polypus  from  an  inversion  of  the 
uterus. 

The  prognosis  as  to  danger  to  life,  depends  upon  the 
amount,  and  character  of  the  hemorrhage.  On  account  of  its 
location  a  polypus  may  set  up  a  great  deal  of  hemorrhage  which 
may  not  only  produce  anemia  but  fatal  symptoms.  The  prog- 
nosis as  to  RELIEF  without  an  operation  depends  upon  the  char- 
acter of  the  polypus,  and  should  be  guarded.  The  operation  for 
the  removal  of  the  polypus  is  simple  and  seldom  terminates 
seriously  if  performed  properlj^. 

TREATMENT.  The  treatment  of  polypi  depends  upon  their 
size,  where  they  are  attached,  length  of  pedicle  and  amount  of 
hemorrhage.  If  the  tumor  is  small  or  of  a  submucous  variety 
it  can  easily  be  cured  by  osteopathic  methods.  This  is  accom- 
plished by  directing  more  arterial  blood  to  the  uterus  and  by 
causing  uterine  contraction.  These  contractions  will  in  most 
cases  produce  expulsion  of  the  tumors.  The  treatment  to 
accomplish  this,  should  be  in  the  lower  lumbar  region,  or  at  the 
sacro-iliac  synchondroses,  since  the  lesions  affecting  the  uterine 
circulation  are  found  at  these  points. 

Torsion  is  sometimes  used.  The  polypus  is  grasped  either 
by  the  hands  or  forceps  and  twisted.  Removal  is  advocated 
in  most  cases  if  the  polypus  is  large,  or  if  it  is  completely  obstruct-" 
ing  the  os,  and  causing  marked  dysmenorrhea. 

CANCER  OF  THE  UTERUS.  Cancer  is  a  malignant  dis- 
ease which  attacks  most  frequently,  the  cervix  uteri,  mammary 


TUMORS    OF   THE    UTERUS.  315 

glands,  and  face.  It  takes  its  name  from  the  word  meaning 
CRAB,  on  account  of  its  tentacles  radiating  in  every 
direction  for  quite  a  distance,  sometimes  six  or  eight 
inches,  thus  making  it  a  very  deeply  seated  disease.  Carcinoma 
is  the  term  commonly  used  for  true  cancer,  although  sarcoma 
and  malignant  adenoma  are  commonly  called  cancers.  They 
undermine  the  constitution  and  in  most  cases  rapidly  lead  to 
death,  hence  are  classified  as  malignant.  It  is  above  all  other 
diseases  the  one  that  a  woman  dreads,  and  rightly  too,  since  its 
termination  is  so  fatal  and  its  course  so  painful  and  distressing. 
Even  if  extirpated,  it  tends  to  recur  in  a  worse  form  and  hastens 
the  death  of  the  patient. 

VARIETIES.  There  are  three  common  varieties  of  cancer, 
viz:  the  medullary  or  encephaloid,  the  scirrhus  and  the 
EPITHELIOMA.  They  differ  in  degree  and  in  the  elements  of 
which  they  are  composed.  The  encephaloid  is  the  softest  and  it 
is  the  most  fatal,  that  is,  its  progress  is  most  rapid  and  produces 
death  soonest.  The  scirrhus  is  hard  on  account  of  the  pre- 
ponderance of  fibrous  tissue,  but  is  rarely  found  attacking  the 
uterus.  The  epithelioma  attacks  the  equamous  epithelium  of 
the  cervix  and  causes  a  typical  multiplication  of  the  cells  which 
invade  the  deeper  tissues.  Another  classification  is  made  ac- 
cording to  the  part  of  the  uterus  affected,  into  cancer  of  the 
vaginal  portion,  cancer  of  the  cervix  and  cancer  of  the  body  of 
the  uterus. 

CAUSES.  The  causes  of  cancer  are  not  very  well  known 
although  certain  constant  factors  are  found  accompanying  the 
disease.  Heredity  has  something  to  do  with  causing  cancer, 
but  unless  acting  in  conjunction  with  other  causes  it  is  not  suffi- 
cient of  itself  to  set  up  a  cancerous  process.  It  will  act  as  a  pre- 
disposing cause,  that  is,  it  may  weaken  the  pelvic  organs  and 


316  DISEASES    OF    WOMEN. 

then  the  exciting  cause  can  the  more  easily  and  readily  act. 

Age  has  considerable  influence  in  the  production  of  the  dis- 
ease. It  occurs  most  frequently  between  the  ages  of  forty  and 
sixty,  it  seldom  occuring  before  the  menopause.  At  this  age 
the  vital  powers  are  lessened,  this  favoring  the  attack.  Any- 
thing which  tends  to  lower  the  vitality  increases  the  liability  to 
the  disease.  Repeated  pregnancies  are  important  causes,  can- 
cer being  most  frequently  found  in  multipara  who  have  borne  at 
least  five  children,  judging  from  the  statistics  on  the  subject. 
Laceration  of  the  cervix  is  the  most  important  of  the  exciting 
causes,  and  I  doubt  if  cases  of  cancer  of  the  cervix  are  found 
without  being  preceded  by  a  bruise  or  a  laceration.  This  causes 
a  constant  irritation,  a  congestion  and  a  weakening,  followed  by 
a  lowering  of  the  vitality  of  the  cervix.  It  is  similar  to  an  epithe- 
lioma of  the  lip  which  is  caused  by  a  jagged  tooth  or  the  pro- 
verbial Irishman's  pipe. 

Cancer  of  the  breast  commonly  arises  in  a  similar  way. 
First,  a  bruise,  a  local  swelling,  patient  getting  scared  and  then 
irritates  the  part  by  frequent  manipulation,  the  surgeon's  knife 
and  then  the  formation  of  the  cancer  proper. 

The  CERVIX  bears  the  brunt  of  coition  and  parturition.  It 
is  also  bruised  by  the  use  of  instruments  introduced  into  the 
uterine  cavity.  If  the  predisposition  is  there,  whether  it  be 
heredity  or  otherwise,  the  irritation  resulting  from  the  bruising 
in  some  cases  results  in  the  cancerous  formation.  I  should  re- 
gard cancers  as  caused  by  a  disturbance  of  the  lymphatic  and 
venous  circulation,  but  principally  by  a  disturbance  of  the 
lymphatic.  It  is  the  result  of  an  injury  of  the  lymphatics, 
and  from  this  results  the  watery  discharge.  The  disturbance 
to  the  blood  supply  is  shown  by  the  fungus-like  appearance 
of  the  new  growth,  and  the  raw  and  angry  appearance  of  the 


TUMORS    OF   THE    UTERUS.  317 

cervix.  This  vascular  disturbance  is  produced  by  the  local  irri- 
tation which  had  followed  the  laceration,  or  else  it  is  due  to  a 
lesion  affecting  the  vaso-motor  centers  of  the  cervix. 

The  LOCAL  INJURY  is  not  sufficient  to  cause  the  disease,  or 
else  every  woman  who  has  been  lacerated  or  had  the  cervix 
bruised  would  have  a  cancer.  There  must  be  something  else 
in  addition,  and  the  bony  lesions  impinging  on  the  nervous  con- 
nection with  the  uterus,  is  to  me  a  very  plausible  cause.  It  is 
the  more  plausible  "when  cases  are  taken  and  cured,  which 
have  been  diagnosed  as  cancers,  by  correcting  these  lesions.  In 
these  cases  the  pelvic  circulation  was  improved  and  the  symp- 
toms either  abated  or  in  some  cases,  entirely  disappeared.  After 
all,  the  cause  of  cancer  is  a  mystery  to  physicians,  there  being 
various  theories,  some  of  which  attribute  it  to  various  imagi- 
nary micro-organisms,  but  no  proven  theory  as  yet  has  been 
found.  To  the  osteopath,  the  disturbances  of  the  lymphatic 
and  venous  circulation  are  the  most  important  causes,  and  all 
his  efforts  should  be  directed  to  restore  the  normal  flow  of  lymph 
and  blood  to  and  from  the  part. 

SYMPTOMS.  The  early  sy:mptoms  are  few  and  mild,  not 
prompting  the  patient  to  seek  the  advice  of  a  physician.  This 
is  one  reason  why  it  is  so  hard  to  cure,  since  it  is  rare  to  get  a 
case  in  the  early  stages.  At  first  the  symptoms  are  local  but 
soon  begin  to  affect  the  constitution  and  undermine  the  general 
health. 

Hemorrhage  is  one  of  the  first  local  symptoms  noticed. 
It  in  patients  who  have  not  reached  or  passed  the  menopause, 
like  hemorrhage  found  in  fibroid  tumors,  appears  first  as  a  men- 
orrhagia.  The  patient  on  account  of  her  age,  she  being  at  or 
near  the  menopause,  usually  attributes  this  to  the  change  of  life, 
thinking  it  to  be   one  of  the  attendant  symptoms.     She  finally 


318  DISEASES    OF    WOMEN. 

consults  a  physician,  if  it  becomes  too  profuse  and  a  well  devel- 
oped cancer  is  frequently  found.  In  other  cases  the  hemor- 
rhages comes  on  irregularly  and  independent  of  the  menstrual 
period.  This  comes  from  rupture  of  the  dilated  vessels  and  from 
an  extension  of  the  ulcerative  process  by  which  the  blood  ves- 
sels are  eroded.  It  may  appear  suddenly  after  an  exertion,  as 
straining  at  stool  or  after  coition. 

With  the  progress  of  the  disease,  the  hemorrhage  increases, 
it  coming  on  in  gushes  and  in  some  cases  threatening  the  pa- 
tient's life.  Sometimes  the  patient  tells  you  that  the  men- 
strual FLOW  NEVER  ENTIRELY  CEASES.  This  is  an  important 
point  if  found  in  a  patient  which  is  in  the  change  of  life,  or  which 
has  just  passed  the  menopause.  Since  cancer  appears  most  fre- 
quently just  after  the  menopause,  any  unusual  hemorrhage 
should  be  properly  examined  as  to  its  cause  and  source,  since 
THE  EARLIER  THE  DISEASE  IS  RECOGNIZED  the  greater  the  prob- 
ability of  a  cure. 

The  DISCHARGE  of  carcinoma  is  of  a  watery  nature  and  of  a 
very  fetid  odor  after  ulceration  has  set  in.  I  have  examined 
patients  in  the  early  stages  of  the  disease  by  means  of  a  speculum, 
in  which  drops  of  water  could  be  seen  to  collect  on  the  cervix. 
The  amount  varies,  but  usually  a  drop  is  secreted  every  few  min- 
utes, so  that  after  awhile  there  is  quite  a  marked  watery  dis- 
charge. This  is  a  symptom  which  is  seldom  found  in  other 
uterine  diseases  and  is  regarded  as  one  of  the  important  indica- 
tions of  cancer.  There  is  no  odor  connected  with  the  discharge 
in  the  early  stages,  which  discharge  is  most  frequently  found 
accompanying  the  papillary  epithelioma  or  the  so-called  "caul- 
iflower" EXCRESCENCE.  After  there  is  ulceration  the  discharge 
becomes  more  offensive  and  increases  in  amount  as  the  disin- 
tegration becomes  more  marked.     The  odor  at  this  stage  is  very 


TUMORS    OF   THE    UTERUS.  319 

NAUSEATING,  markedly  penetrating  and  clings  to  the  examining 
finger  for  sometime,  regardless  of  the  efforts  to  remove  it.  The 
discharge  is  called  carcinomata  ichor  or  "cancer  juice." 

Pain  is  not  an  important  symptom  in  the  early  stages  of 
cancer,  but  in  the  later  stages  becomes  very  constant.  After 
ulceration  begins,  sharp  lancinating  pains  are  felt  in  the  pelvic 
region  and  sometimes  shooting  through  to  the  back  and  re- 
flected down  the  limbs.  Sometimes  it  is  a  dull  gnawing  pain 
which  is  located  in  the  small  of  the  back  or  deep  down  in  the  pel- 
vis. Occasionally  this  pain  is  reflected  to  the  mammary  glands, 
settmg  up  a  reflex  functional  disturbance  of  the  glands.  Local 
peritonitis,  which  accompanies  nearly  all  those  cancerous  condi- 
tions of  the  uterus,  is  also  productive  of  pain  which  is  localized. 
The  adhesions  which  are  present,  prevent  the  diffuse  form  of 
peritonitis  in  most  cases. 

The  disease  may  extend  to  the  neighboring  organs,  pro- 
ducing ulceration  or  other  disturbance  in  them.  The  bladder 
becomes  irritable,  frequent  micturition  is  present,  and  in  some 
cases  cystitis,  and  painful  urination.  The  kidneys  on  account 
of  the  pressure  on,  or  the  extension  to  them  of  the  disease  from 
the  uterus,  are  frequently  affected.  There  may  be  hydronephro- 
sis, uremia  or  organic  disturbances  of  the  kidney. 

Constipation  is  present  on  account  of  the  pain  associated 
with  defecation,  dryness  of  the  feces  resulting  from  the  watery 
discharge,  and  weakness  of  the  expulsive  forces  on  account  of 
the  extension  of  the  disease  to  the  rectum.  Diarrhea  follows  in 
some  cases  in  which  the  rectum  is  irritated  by  the  invasion  of 
the  cancer.  The  lymphatic  glands  in  the  lumbar  region  are 
enlarged  and  tender,  and  care  should  be  exercised  in  treating  the 
abdomen  lest  there  be  bruising  or  injury  of  these  glands. 

GENERAL  SYMPTOMS.     In  addition  to  the  local  symptoms 


320  DISEASES    OF   WOMEN. 

mentioned,  there  are  certain  general  symptoms  which  are 
secondary  to  the  local  trouble.  The  most  marked  are:  emacia- 
tion and  GENERAL  DEBILITY.  In  the  early  stages  the  patient 
may  be  apparently  healthy,  but  after  there  is  much  ulceration, 
the  skin  becomes  anemic  and  of  a  straw  color;  there  is  progressive 
loss  of  FLESH  and  the  patient  has  a  careworn  appearance. 
These  facial  symptoms  are  called  cancerous  cachexia  or  can- 
cerous facies.  The  appetite  is  deranged  and  there  is  anorexia, 
nausea  and  sometimes  vomiting.  There  is  sleeplessness,  anxiety, 
anemia  and  a  general  loss  of  energy. 

PHYSICAL  SIGNS.  In  making  a  local  examination  it  is 
well  to  protect  the  finger  by  coating  it  over  with  glycerine.  This 
lessens  the  danger  of  infection  and  assists  in  the  removal  of 
the  fetid  odor  which  clings  to  the  finger. 

In  a  typical  case,  the  inside  of  the  cervix  is  soft  and  friable, 
while  the  rim  of  the  cervix  is  hard.  The  mucous  membrane  is 
found  to  be  partially  inverted,  which  gives  it  a  rough  or  cauli- 
flower appearance.  There  is  proneness  to  hemorrhage  on  the 
least  irritation  by  the  examining  finger,  and  particles  of  the 
GROWTH  CAN  BE  READILY  BROKEN  off  with  the  finger  nail.  The 
rough  irregular  mass  is  felt  and  with  the  spculum,  the  cauliflower 
fundus-like  bleeding  tumor  can  be  seen.  Particles  are  frequently 
sloughed  off  and  discharged  per  vagina,  that  is,  if  it  is  friable. 

The  microscopic  examination  reveals  a  fibrous  stroma  with 
alveoli  which  contain  irregular  cells  of  an  epithelial  type.  In 
cases  of  advanced  standing  in  which  the  vaginal  examination  is 
too  painful  and  productive  of  hemorrhage,  a  rectal  examination 
can  be  made.  The  uterus  is  felt  to  be  fixed  and  the  cancerous 
area  outlined.  A  speculum  should  be  used  in  most  cases  in 
which  cancer  is  suspected,  since  inspection  is  the  best  method 
by  which  to  diagnose  the  disease. 


TUMORS    OF   THE    UTERUS.  321 

DIFFERENTIAL  DIAGNOSIS.  The  diagnosis  of  cancer  is  some- 
times very  hard  as  it  is  quite  often  mistaken  for  other  diseases, 
or  rather  it  is  the  reverse,  that  is,  other  diseases  are  more  fre- 
quently MISTAKEN  FOR  CANCER.  Many  cases  that  come  to 
the  A.  T.  Still  Infirmary  that  had  been  diagnosed  as  cancers, 
turn  out  to  be  something  else,  such  as  a  simple  tumor,  laceration 
or  ulceration. 

It  is  diagnosed  from  fibroid  tumors  by  the  hemorrhage; 
its  amount  and  onset.  In  fibroid  tumors  it  is  gradual  in  its  onset; 
not  so  constant  nor  profuse  except  in  some  cases  of  the  sub- 
mucous variety.  In  a  fibroid  there  is  absence  of  a  fungus-like 
mass,  of  a  fetid  odor,  of  friability,  and  the  disease  appears 
before  the  age  of  forty-five.  There  Is  absence  of  constitutional 
symptoms  and  it  runs  a  much  more  chronic  course  than  in  can- 
cer. The  enlargement  is  different  as  to  size,  location  and  ap- 
pearance. Fibroid  tumors  are  usually  located  on  the  fundus, 
develop  slowly  and  produce  enlargement  of  the  abdomen,  while 
cancers  are  found  on  the  cervix,  develop  rapidly  and  produce 
no  enlargement  of  the  abdomen.  A  polypus,  in  which  there  has 
been  sudden  torsion  of  the  pedicle,  may  be  mistaken  for  a  cancer 
on  account  of  the  discharge,  odor' and  the  hemorrhage.  The 
other  symptoms  of  cancer  are  absent.  On  examination  of  the 
cervix  no  growth  is  found,  but  on  examination  of  the  uterine  cav- 
ity the  tumor  can  be  outlined. 

An  EROSION  or  ulceration  of  the  cervix  is  most  frequently 
mistaken  for  cancer.  Consider  the  odor  of  the  discharge,  length 
of  standing,  constitutional  symptoms,  and  amount  of  pelvic 
disturbances.  On  examination  of  the  ulcer  it  is  not  like  a  cauli- 
flower in  appearance,  not  friable  and  is  localized  and  yellowish 
in  color,  while  cancer  is  red. 

A  LACERATION    that  has  not  healed,  m.ay  give  rise  to  symp- 


322  DISEASES   OF   WOMEN. 

toms  of  cancer,  but  fromhistory,  absence  of  characteristic  cancer 
symptoms  and  locating  the  rupture  of  the  cervical  wall  by  the 
examining  finger  and  by  use  of  the  speculum,  it  can  be  easily 
differentiated  from  cancer.  In  laceration,  the  splits  in  the  cer- 
vix radiate  from  within  outward  and  are  regular,  but  in  cancer  the 
fissures  are  irregular,  sometimes  running  crosswise  of  the  cervix. 

To  SUMMARIZE  the  diagnostic  symptoms  of  a  cancer,  note  the 
RAPID  PROGRESS  of  the  disease,  age  of  patient,  she  being  above 
forty  years  of  age,  evidences  of  heredity,  presence  of  the  char- 
acteristic symptoms  and  signs  of  malignancy  such  as  pain, 
hemorrhage,  fetid  discharge,  pelvic  and  reflected  pains,  fixation 
of  the  body  of  the  uterus,  involvement  of  adjacent  parts,  tend- 
ency to  resist  treatment  and  to  recur  after  removal,  and  the  cache- 
tic appearance  of  the  patient.  The  physical  signs  that  are  found 
by  examination  with  the  finger  and  speculum,  evidences  of  metas- 
tasis and  growths  elsewhere,  and  the  microscopical  appearance 
of  portions  of  the  cancerous  growth  make  the  diagnosis  sure. 

PROGNOSIS.  The  prognosis  in  cases  of  true  cancer  is  very 
unfavorable,  both  as  to  cure  and  relief.  In  cases  of  supposed 
cancer  it  is  favorable.  I  have  seen  cases  or  conditions  that  were 
diagnosed  as  cancer  which  were  cured,  and  on  this  account,  if 
the  case  is  taken  in  the  very  early  stages,  there  is  a  chance  of  it 
not  being  a  cancer  and  can  be  eventually  cured.  Consider  this 
in  making  a  prognosis  since  you  should  be  very  guarded  as  to  the 
outcome  of  the  disease.  Never  pronounce  a  case  as  one  of  can- 
cer until  you  are  sure  of  your  diagnosis,  for  the  patient  will  likely 
get  worse  from  the  very  thoughts  of  having  the  dreaded  disease. 

If  it  is  one  of  true  cancer,  its  course  is  rapid  and  death 
usually  results  within  two  years,  sometimes  a  great  deal  sooner, 
especially  in  the  encephaloid  variety.  Under  osteopathic  treat- 
ment a  great  many   cases  of  supposed  cancer  have  been  cured, 


TUMORS    OF   THE    UTERUS,  323 

but  I  have  never  seen  a  case  of  a  truly  well  developed  cancer  cured. 
In  the  later  stages  the  pain  and  suffering  can  be  markedlj^  re- 
lieved, and  on  this  account  if  on  no  other,  the  treatment  is  a 
wonderful  advancement  on  the  usual  methods. 

MODES  OF  DEATH.  The  patient  may  die  from  hemorrhage, 
but  this  is  rare.  Cancer  usually  kills  by  gradual  emacia- 
tion AND  malnutrition.  There  exists  disintegration  of  the 
RED  BLOOD  CORPUSCLES  which  lowers  the  vitality  of  the  blood 
and  produces  the  hematogenous  form  of  jaundice.  Complica- 
tions such  as  peritonitis,  bowel  troubles,  emboli  lodging  in  the 
various  parts  of  the  body,  causing  secondary  cancerous  forma- 
tions, all  help  to  hasten  the  fatal  end. 

TREATMENT.  The  surgical  treatment  is.  removal  of  the 
cancerous  mass  just  as  soon  as  possible.  If  in  early  stages, 
unless  it  is  entirely  removed,  the  operation  only  hastens  the 
progress  of  the  disease  by  lowering  the  vitality  of  the  tissues.  A 
great  many  cases  of  supposed  cancer  are  helped  to  be  developed 
into  true  cancer,  and  that  very  rapidly,  by  attempt  at  removal. 
If  it  were  possible  to  completely  remove  the  diseased  portion,  an 
operation  might  be  successful,  but  on  account  of  the  tentacles 
and  branches  running  out  into  the  adjacent  structures  for  several 
inches,  it  makes  a  complete  removal  almost  impossible.  If  oper- 
ated on  in  the  later  stages  the  cure  is  still  more  improbable  and 
for  these  reasons  an  operation  is  contraindicated.  The  opera- 
tion usually  performed  is  one  of  hysterectomy,  either  vaginal 
or  abdominal. 

The  osteopathic  treatment  is  one  directed  to  build  up  the 
quality  of  blood  and  to  improve  the  circulation  through  the 
affected  area.  This  is  accomplished  by  treatment  along  the 
lumbar  and  sacral  regions.  I  have  a  record  of  several  cases  that 
were  diagnosed  as  cancer  that  were  cured,  in    which  the  treat- 


324  DISEASES   OF   WOMEN. 

ment  was  almost  entirely  applied  to  the  lumbar  and  sacral  re- 
gions. In  these  there  were  the  usual  symptoms  of  cancer,  the 
irregular  growth,  fetid  odor,  hemorrhage  and  pain. 

If  the  discharge  is  irritating  or  of  a  very  fetid  odor,  a  carbol- 
ized  douche  should  be  given. 

The  palliative  treatment  consists  of  inhibition  over  the  sen- 
sory nerves  connected  with  the  uterus.  These  can  be  reached 
through  the  lower  lumbar  and  sacral  regions.  The  pain  and 
aching  can  be  relieved,  but  only  temporarily,  since  no  permanent 
results  follow  that  kind  of  treatment.  Various  cancer  ''pastes" 
and  "sure  cures"  are  advertised,  but  have  very  little  effect  on 
the  course  of  the  disease  except  that  they  so  often  make  it  worse. 

Sarcoma  of  the  uterus  is  a  malignant  tumor  which  differs 
from  carcinoma  in  that  it  belongs  to  the  connective  tissue  group 
and  is  of  an  embryonic  type.  It  rarely,  as  compared  with  car- 
cinoma, attacks  the  uterus.  It  may  appear  at  any  age  but  occurs 
most  frequently  at  or  immediately  after  the  menopause.  It,  un- 
like cancer,  attacks  the  fundus  most  frequently.  The  cause  of 
the  disease  is  unknown  but  is  supposed  to  be  similar  to  that  pro- 
ducing cancer. 

SYMPTOMS.  The  symptoms  are  very  much  like  those  pro- 
duced by  cancer.  The  hemorrhage,  pain,  especially  after  the 
disease  is  well  developed,  watery  discharge  and  the  cachexia  or 
constitutional  symptoms  are  like  those  of  cancer.  The  round 
CELL  variety  is  more  malignant  than  cancer,  it  producing  death 
within  a  few  months.  It  spreads  by  way  of  the  blood  vessels 
instead  of  the  lymphatics  as  we  find  in  cancer. 

Sometimes  a  myoma  may  develop  into  a  sarcoma,  if  the  tu- 
mor has  been  bruised  or  injured  to  any  great  extent.     For  this 

REASON,  care  SHOULD  BE  TAKEN  NOT  TO  BRUISE  A  TUMOR  BY  A 
too   hard   treatment   over   it   OR   ELSE   IT   MAY    BECOME   MALIG- 


TUMORS    OF   THE    UTERUS.  325 

NANT.  In  some  cases  the  growth  becomes  rapid,  pain  severe 
and  termination  fatal  in  a  very  short  time. 

Its  diagnosis  as  to  malignancy  is  based  upon  the  above 
symptoms,  that  is,  fetid  discharge,  hemorrhage,  pain,  rapid  pro- 
gress, and  constitutional  symptoms.  It  can  be  diagnosed  from 
cancer  from  its  position,  it  being  found  in  the  connective  tissue 
of  the  fundus,  also  by  microscopic  examination,  since  it  is  com- 
posed of  connective  tissue  and  cancer  of  epithelial  cells. 

The  treatment  is  the  same  as  for  cancer.  The  prognosis  is 
grave.  It  can  be  relieved  temporarily  but  a  complete  cure  is 
rare. 

Sometimes  there  are  cases  of  sloughing  fibroid  tumors  that  have 
been  diagnosed  as  sarcomata,  that  were  cured  by  the  treatment, 
but  true  sarcoma  is  usually  incurable.  As  in  cancer  be  sure  of 
your  diagnosis  before  telling  the  patient,  because  it  means  all  to 
the  patient. 


326  PISEASES    OF    WOMEN. 


LACERATION  OF  THE  CERVIX. 


LACERATION  OF  THE  CERVIX  is  a  rupture  of  the  cervix 
uteri  in  one  or  more  places  during  childbirth,  or  from  forci- 
ble DILATATION  of  the  OS  by  means  of  an  instrument.  It  is  a  very 
common  condition  and  one  that  is  productive  of  a  great  many 
symptoms  both  local  and  reflex.  I  have  examined  case  after 
case  of  multiparous  women  in  which  the  symptoms  were  those  of 
nerve  waste,  loss  of  energy,  nervousness,  hysteria,  and  in  most  of 
them  there  was  a  laceration  accompanied  by  subinvolution  and 
endometritis. 

It  is  caused  in  various  ways,  but  the  most  important  cause  is 

MEDDLESOME   MIDWIFERY  and  HASTILY   CONDUCTED   LABORS.       The 

cervix  is  not  fully  prepared  to  dilate  sufficiently  to  transmit  the 
fetal  head  until  the  end  of  the  normal  period  of  gestation.  If 
labor  is  induced  or  hurried,  the  cervix  instead  of  stretching  as  it 
should,  is  forcibly  torn,  but  if  left  to  nature,  a  very  few  cases  of 
laceration  will  occur.  Nature  never  intended  that  a  woman 
should  be  lacerated  at  childbirth.  The  natural  process,  if  left 
alone,  unless  there  is  a  precipitate  delivery,  or  the  parts  are  dis- 
eased, WILL  cause  a  natural  STRETCHING  and  dilatation,  which 
prevents  the  tissues  from  tearing,  but  sometimes  the  accoucher 
thinks  he  can  improve  on  nature  but  dismally  fails,  although  the 
child  is  born  sooner. 

I  think  the  use  of  ergot  and  quinine  or  any  other  drug 
used  to  bring  on  uterine  contractions,  is  to  blame  as  much  as  any 
one  thing.  These  drugs  cause  a  contraction  of  the  uterine  mus- 
cles. The  fundus  being  larger  and  stronger  than  the  cervix  con- 
tracts with  greater  force  and  forces  the  fetal  head  downward 


LACERATION    OF   THE    CERVIX.  327 

against  the  resisting  os.  Instead  of  relaxing  the  muscle  fibers 
of  the  cervix,  it  produces  a  contraction,  but  this  contraction" 
16  overcome  by  the  greater  force  from  above,  the  contraction  of 
the  fundus,  and  as  a  result  the  os  is  forcibly  dilated  and  conse- 
quently the  constrictor  fibers  are  torn.  Sufficient  time  is  not 
given  for  relaxation,  since  it  takes  quite  a  while  in  some  cases, 
for  those  fibers  to  relax  and,  as  a  result,  the  fibers  are  ruptured. 

Improper  treatments  applied  to  the  uterus  while  in  the 
non-pregnant  state,  such  as  the  use  of  the  dilator,  sound  or 
the  application  of  caustics  or  astringents,  harden  the  cervical 
tissues.  This  retards  or  hinders  dilatation  and  the  tissues  tend 
to  tear  rather  than  stretch. 

A  TOO  rapid  delivery  has  a  similar  effect,  that  is,  time  is 
not  given  for  relaxation.  High  forceps  delivery  produces 
laceration  in  nearly  every  case.  In  case  of  large  fetal  head, 
a  rigid  os  or  any  diseased  condition  of  the  cervix,  there  is  a  lia- 
bility of  laceration,  even  if  precaution  is  taken.  However,  the 
greatest  number  of  cases  result  from  the  physician  being  in  too 
great  a  hurry.  If  the  labor  is  slow,  something  is  administer- 
ed to  bring  on  the  labor  pains,  or  if  they  are  feeble  he  resorts  to 
the  use  of  forceps.  In  a  case  of  a  deformed  pelvis  sometimes  it  is 
impossible  to  prevent  laceration,  also  in  cases  in  which  rapid 
delivery  is  necessary,  such  as  placenta  previa  or  breech  delivery. 

VARIETIES.  A  laceration  usuall}'^  takes  place  laterally. 
If  only  one  side  is  torn  it  is  called  a  unilateral  laceration;  if  two 
sides,  a  bilateral;  if  at  more  than  two  places  it  is  called  a  stellate 
laceration.  The  laceration  varies  from  a  slight  tear  which  heals 
in  a  few  days,  to  a  complete  laying  open  of  the  cervical  portion 
of  the  uterus  and  extending  to  the  roof  of  the  vaginal  vault.  In 
some  cases  the  cervix  is  literally  slit  into  halves.  This  leaves  a 
raw  open  wound  which  is  irritable  and  gives  rise  to  inflammatory 
conditions  of  the  uterus  and  vagma. 


328  DISEASES    OF    WOMEN. 

SYMPTOMS.  The  immediate  symptoms  are  those  of  arterial 
HEMORRHAGE.  It  may  be  very  profuse;  the  quantity  depending 
upon  the  depth  of  the  tear  and  the  number  of  vessels  injured. 
The  patient  will  complain  of  a  burning  sensation  referred  to  the 
cervix,  also  local  pain  or  reflex  ache.  The  lochia  usually  con- 
tinues longer  than  normal  and  the  changes  delayed. 

The  secondary  symptoms  are  varied.  If  the  patient  is 
strong,  it  will  not  affect  her  for  sometime,  but  if  she  is  weak 
to  begin  with,  the  laceration  very  soon  begins  to  weaken  her 
more  and  set  up  reflex  troubles. 

The  local  symptoms  are  those  of  chronic  inflammation.  The 
cervix  is  congested,  soft,  and  the  os  patulous.  The  disturbances 
to  the  circulation  affect  secretion  as  is  evident  by  the  leucorrheal 
discharge. 

Involution  of  the  uterus  is  retarded,  this  producing  a  con- 
dition called  SUBINVOLUTION.  Menstruation  is  irregular  and 
the  flow  usually  is  increased  in  amount.  The  reflex  and  general 
symptoms  are  many,  in  fact  all  varieties  are  found  in  cases  of 
bad  laceration. 

Neuralgia  in  different  parts  of  the  body  is  sometimes  present. 
It  very  frequently  assumes  a  form  of  intercostal  neuralgia 
or  in  some  cases,  neuralgia  of  the  fifth  cranial  nerve.  The 
cervix  may  be  very  sensitive  if  in  the  recent  state,  and  the  pain 
has  been  compared  to  that  of  an  ache  due  to  an  exposed  nerve. 
Nerve  filaments  may  be  caught  in  scar  tissue  which  is  formed, 
this  causing  reflected  pains.  Backache  in  the  lower  lumbar 
and  sacral  regions  is  common.  The  limbs  may  ache  or  as  many 
a  patient  describes  it,  feel  heavy.  This  is  probably  due  to  the 
INCREASED  WEIGHT  of  the  utcrus  and  inflammation  of  the  nerve 
terminals  in  the  uterus.  The  pelvic  floor  is  weakened  and  there 
is  a  tendency  to  a  backward  and  downward  displacement  of  the 
heavy  subinvoluted  uterus. 


LACERATION    OF    THE    CERVIX.  329 

Reflex  troubles  are  very  marked.  Hysteria  in  its  worst 
form  is  found  in  eases  of  laceration  of  the  cervix.  It  causes  a 
disturbance  of  the  nervous  equilibrium  on  account  of  the  con- 
stant loss  of  nerve  force,  and  the  patient  becomes  unable  to  con- 
trol herself.  There  will  be  in  some  cases  a  choking  sensation, 
PAIN  in,  and  contraction  of,  one  limb,  flatulency,  anuria,  aphonia, 
and  in  many  cases,  the  patient  may  entirely  lose  control  of  her- 
self and  give  vent  to  her  feelings  by  screaming  or  crying.  This 
forms  a  safety  valve  by  which  the  excessive  pressure  is  relieved. 
Again  I  have  seen  cataleptic  conditions,  resulting  from  lacera- 
tion, the  patient  remaining  stiff  for  some  hours.  The  constant 
loss  of  nerve  force,  causes  a  change  in  the  disposition,  the  pa- 
tient becoming  irritable,  and  there  is  inability  to  concentrate 
her  mind,  and  she  has  headaches,  marked  weakness  and  general 
debility.  Digestion  and  absorption  are  deranged,  thus  causing 
malnutrition.  If  a  patient  presents  herself  suffering  with  the 
above  symptoms  and  dates  the  trouble  back  to  childbirth,  lac- 
eration should  at  once  be  suspected. 

PHYSICAL  SIGNS.  By  means  of  the  finger  in  vaginal  ex- 
amination, the  indentation  or  fissuring  of  the  cervix  can  be  dis- 
tinctly outlined.  The  os  is  usually  patulous  on  account  of  the 
attending  subinvolution. 

The  various  Nabothian  glands  which  open  on  the  cervical 
mucous  membrane  become  inflamed.  The  ducts  become  filled 
and  little  retention  cysts  form,  which  are  called  Nabothian 
CYSTS  from  the  name  of  the  glands.  At  first  they  are  soft,  of 
about  the  size  of  a  small  shot  and  when  punctured  discharge  a 
gelatinous  fluid.  Afterwards  they  become  hardened  and  em- 
beded  in  the  cervix.  After  this  takes  place,  they  resemble  on 
palpation  shot  sunken  in  the  substance  of  the  cervix.  They  are 
often  quite  extensive  and  are  diagnostic  of  a  condition  of  cystic 


330  DISEASES    OF    WOMEN. 

degeneration  of  the  cervix,  which  is  the  immediate  result  of  the 
vascular  changes  incident  to  laceration  of  the  cervix. 

The  EVERTED  CERVICAL  MUCOSA  can  be  felt  as  a  roughened 
surface.  Various  names  have  been  applied  to  this  condition  of 
the  roughening  and  eversion  of  the  mucous  membrane,  such  as 
erosion,  granular  erosion,  excoriation  and  ulceration.  Some- 
times the  lips  are  turned  back  so  far,  as  in  marked  bilateral  lac- 
eration, that  the  indentation  can  not  be  felt;  only  the  roughened 
surface  being  recognized.  To  this  has  been  given  the  name  of 
BELL-SHAPED  CERVIX  on  account  of  the  lower  part  of  the  cer- 
vix being  wider  than  the  upper  part.  In  certain  cases  the  cer- 
vical endometrium  is  partially  everted.  This  is  found  most  fre- 
quently on  the  anterior  lip  and  is  the  result  of  eversion  from 
laceration.  The  os  is  crescent-shaped  and  the  shorter  lip  is 
thin. 

If  the  case  cannot  be  diagnosed  definitely  by  digital  examina- 
tion a  speculum  should  be  introduced.  By  exposing  the  cervix 
by  means  of  this  instrument,  the  granular  surfaces,  the  flatten- 
ed cervix,  the  hypertrophy  of  the  lips  and  the  radiating  fissures 
can  be  seen.  If  vulsella  are  now  used  to  pull  down  or  unroll  the 
everted  lips,  the  degree  of  the  tear  can  be  definitely  ascertained. 

It  is  diagnosed  from  an  endometritis  with  slight  protrusion 
of  the  endometrium,  by  the  size  of  the  cervix  and  the  shape  of 
the  OS,  as  determined  by  inspection.  From  cancer  it  is  diagnosed 
by  the  absence  of  cancerous  symptoms,  and  especially  by  the 
absence  of  friability  and  tendency  to  hemorrhage  on  slight  irri- 
tation. 

Prophylaxis.  An  osteopath  should  not  permit  laceration 
to  take  place  unless  a  deformity  or  marked  abnormality  exists. 
The  best  way  to  cure  laceration  is  to  prevent  it.  This  is  done 
by  first  dilating  the  os  uteri  by  inhibition  of  the  clitoris;  sec- 


LACEKATIOX    OF   THE    CERVIX.  331 

OND,  not  hastening  labor  by  artificial  means;  third,  by  not  using 
drugs  or  instruments;  and  fourth,  by  regulating  and  controlling 
the  rapidity  of  the  birth  of  the  child. 

If  dilatation  is  rapid,  it  is  not  best  to  let  the  head  be  forced 
out  of  the  uterus  with  a  strong  pain,  but  hold  it  back  and  deliver 
between  pains  or  at  the  latter  part  of  it.  Between  pains  I  rim 
OUT  THE  OS  with  one  or  more  fingers  by  which  symmetrical  dilata- 
tion can  be  secured.  If  one  side  of  the  cervix  becomes  very  thin, 
it  tends  to  tear  when  a  pain  forces  the  head  against  it.  To  avoid 
this  force  the  head,  when  the  pain  is  on,  against  the  opposite 
side,  in  other  words,  guide  the  passing  of  the  fetus,  especially 
the  head,  out  of  the  uterus,  which,  when  carefully  done  will  pre- 
vent laceration.  In  a  normal  labor  no  blood  should  be  lost  prior 
to  the  clots  expelled  immediately  after  the  completion  of  the 
second  stage  and  with  the  placenta.  The  least  amount  of 
BLOOD  before  the  second  stage  is  completed  is  indicative  of 
A  TEARING  OF  SOME  part  of  the  genital  tract,  usually  the  cervix. 
Out  of  nearly  one  thousand  cases  delivered  by  Dr.  C.  E.  Still  and 
mj'self,  I  know  of  but  few  cases  in  which  we  had  complete  care 
of  the  case,  that  there  were  lacerations,  and  they  were  abnormal 
cases,  in  that  the  pelvis  was  deformed,  the  uterus  diseased,  the 
fetus  very  large,  or  the  fetus  had  to  be  delivered  rapidly  on  ac- 
count of  the  hemorrhage  from  a  malposed  placenta. 

TREATMENT.  The  treatment  should  be  directed  to  get 
union  and  healing  of  the  irritated  and  inflamed  edges.  If  there 
is  in  the  parts,  a  chronic  inflammation  with  degeneration,  such  as 
is  the  case  in  erosion  or  ulceration,  it  is  hard  to  get  the  edges  to 
unite;  often  the  stitches  making  the  condition  worse.  If  the 
parts  are  not  badly  inflamed,  that  is  if  the  inflammation  is  not 
chronic,  union  can  be  secured  by  an  operation.  This  operation 
is    called    trachelorraphy.      In    chronic  cases,  the  surfaces  are 


332  DISEASES    OF    WOMEN. 

first  denuded  and  then  sutured.  Rest  of  the  part  should  follow 
the  operation  until  complete  union  has  taken  place.  Coition 
should  be  forbidden  as  long  as  there  is  any  inflammation  what- 
ever, lest  the  condition  be  made  worse  by  the  congestion  and  irri- 
tation of  the  parts. 

If  the  case  is  a  chronic  one,  and  the  inflammation  has  re- 
ceded, an  operation  will  do  little  if  any  good,  unless  there  has 
been  an  excessive  amount  of  fibrous  material  deposited.  In 
these  kind  of  cases  a  "V"  shaped  plug  is  usually  removed, 
this  lessening  the  hypertrophy  and  relieving  the  impingement 
on  the  nerve  terminals.  I  have  seen  large  lacerations  which 
have  spontaneously  healed,  which  caused  the  patient  no  appar- 
ent trouble.  I  doubt  that  scar  tissue  in  the  cervix  causes  any 
trouble  whatever. 

Amputation  of  the  cervix  is  resorted  to  in  cases  of  deep  stel- 
late laceration.  In  some,  the  condition  of  the  patient  is  better- 
ed, in  others  made  worse.  The  writer  has  seen  several  cases  in 
which  the  operation  had  been  performed,  in  which  the  condition 
was  made  a  great  deal  worse  as  far  as  the  uterus  was  concerned. 
Dysmenorrhea  of  a  very  bad  type  often  follows.  Cystic  de- 
generation with  its  softening  of  the  uterus  occurs  in  other  cases. 
In  one  case  treated  by  the  writer  the  cramps  came  on  as  many 
as  ten  days  before  the  flow  and  continued  about  two  weeks  at 
each  period.  They  were  so  strong  that  the  patient  was  exhausted, 
the  menstrual  period  being  a  great  deal  more  painful  than  par- 
turition. This  patient  was  entirely  free  from  menstrual  pain 
prior  to  the  operation,  but  pain  appeared  at  the  first  menstrua- 
tion after.  On  local  examination  there  was  found  two  openings 
to  the  uterus;  also  a  slight  displacement.  The  pains  could  be 
lessened  a  great  deal  by  instrumental  dilatation  immediately 
before  the  menstrual  period. 


LACERATION    OF    THR    CERVIX.  333 

It  is  BEST  to  REPAIR  the  tear  in  the  cervix  as  soon  as  there 
is  marked  involution,  and  that  is  about  the  fifth  or  sixth  week. 
This  prevents  secondary  inflammation  and  guards  against  can- 
cerous growths.  Some  advocate  an  immediate  operation,  but 
it  is  not  indicated  unless  there  is  profuse  hemorrhage.  There 
is  difficulty  in  recognizing  the  extent  of  the  injury,  the  cer- 
vix being  large  and  flabby,  and  thus  it  makes  the  operation  un- 
certain unless  the  uterus  has  regained  to  a  certain  extent,  its 
former  size.  The  dangers  of  infection  are  increased  by  an 
operation  at  this  time  unless  strict  antiseptic  precautions  are 
taken.  Such  precautions  are  not  always  possible  at  private 
homes  at  which  most  cases  occur. 

The  cases  that  the  osteopath  will  meet  with  are  chronic  ones, 
since  it  is  a  very  rare  thing  to  have  a  laceration  occur  which  is 
deep  enough  to  cause  either  local  or  reflex  effects,  if  handled  by 
our  osteopathic  methods.  If  a  patient  were  to  come  to  you  suf- 
fering with  leucorrhea,  menstrual  disorders,  pain,  reflex  and  local, 
and  an  erosion  and  ulceration  is  found,  the  case  should  first  be 
treated  for  awhile  before  an  operation  is  advised  even  if  one 
were  needed.  If  the  treatment  does  not  relieve  the  inflammation 
then  an  operation  should  be  advised,  whereby  the  two  edges  can 
be  approximated. 

1  have  cured  numbers  of  cases  in  which  there  were  marked 
hicerations.  This  can  be  done  if  there  is  not  too  much  inflam- 
mation or  irritation  to  the  parts,  which  prevents  healing.  The 
treatment  used  is  one  directed  to  control  the  pelvic  circu- 
lation. Treatment  applied  over  the  lumbar  and  sacral  re- 
gions, causes  increased  vaso-motor  tonicity.  Manipulation  over 
the  course  of  the  abdominal  and  pelvic  veins  removes  obstruc- 
tions to  the  return  flow  of  blood.  By  keeping  the  patient  quiet, 
iuul  continuing  the  treatment  for  few  weeks,  a  great  many  of 


334  DISEASES    OF   WOMEN. 

the  symptoms  can  be  relieved.  Stimulation  of  the  nerve  cen- 
ters of  the  uterus,  located  in  the  lower  lumbar  region,  produces 
contraction  of  the  uterine  muscle  fibers.  This  forces  the  venous 
blood  out  of  the  uterus  and  results  in  lessening  the  size 
of  it.  Lesions  along  the  lower  lumbar  and  sacral  regions  some- 
times prevent  complete  involution  and  increase  the  congestion 
and  inflammation  which  attend  laceration.  By  correcting  these 
lesions,  the  congestion  and  inflammation  are  lessened,  thereby 
increasing  the  probability  of  a  cure  without  an  operation. 
Although  an  operation  is  often  indicated  if  the  case  is  compara- 
tively a  recent  one  since  it  is  a  surgical  condition,  the  treatment 
will  very  materially  help  the  healing  of  the  parts,  and  should  be 
given.  Osteopathy  is  certainly  quite  an  adjunct  to  sur- 
gery. If  by  the  treatment  the  blood  is  kept  circulating  through 
the  uterus  it  lessens  the  pain  and  shortens  the  length  of 
time  of  healing. 


EROSION    OF   THE    CERVIX.  335 


EROSION  OF  THE  CERVIX. 


Erosion  of  the  Cenix  Is  a  circular,  irregular,  roughened 
patch  surrounding  the  os,  which  is  raw  in  appearance.  Some- 
times there  are  granular  patches  with  irregular  outlines  which 
extend  beyond  the  limits  of  the  os  externum.  The  pavement 
epithelium  has  been  partly  or  wholly  destroyed  and  replaced  by 
newly  formed  cells,  which  are  columnar  in  shape.  New  gland 
tissue  is  formed  which  is  secreting  and  resembles  in  structure 
the  cervical  mucous  membrane.  This  leads  to  abnormal  secre- 
tions such  as  leucorrhea. 

The  term  ulceration  has  been  applied  to  this  condition,  but 
erosion  is  a  better  term,  since  very  rarely  there  are  actual  ulcer- 
ative changes.  Ectropium  or  eversion  of  the  mucous  membrane, 
is  a  term  used  to  describe  the  condition  when  there  is  laceration, 
but  does  not  describe  the  secreting  surface  beyond  the  os  externum. 

CAUSES.  In  the  young  and  the  nulliparous  woman,  ex- 
posure during  menstruation  is  a  common  cause.  Imprudent 
exercise  or  over  work  at  the  menstrual  period,  produces  a  dis- 
turbance of  the  uterine  circulation.  If  this  is  persisted  in  month 
after  month,  congestion  or  even  inflammation  will  result.  Let 
us  examme  one  of  those  eroded  surfaces.  It  shows  vascular 
changes,  for  it  is  congested,  and  since  papillae  and  granules  of 
different  size  are  formed  over  the  diseased  area.  To  produce 
this  the  circulation  must  be  impaired,  and  m  most  cases  this  is 
a  venous  rather  than  an  arterial  disturbance.  Since  venous 
blood  supports  only  the  lower  form  of  life,  connective  tissue  and 
hypertrophied  epithelium  are  in  abundance. 

The  causes  of  this  congestion  in  nullipara,  in  addition  to  ex- 


336  DISEASES   OF   WOMEN. 

posure  during  menstruation,  are  lesions  deranging  the  nerve 
supply.  If  this  collection  of  the  blood  in  the  mucous  membrane 
lining  the  os  becomes  chronic,  these  erosive  changes  follow.  Cer- 
tain women  are  predisposed  to  chronic  congestion  of  all  the  mu- 
cous membranes.  The  writer  recently  treated  a  case  of  mem- 
branous dysmenorrhea  in  which  there  was  hemorrhage  from  nearly 
all  the  mucous  membranes  during  the  menstrual  period.  There 
was  a  small  erosion  of  the  cervix,  and  on  this  account  the  uterus 
had  been  curetted,  with  little  or  no  benefit. 

In  MULTIPARA,  childbirth  is  the  most  common  cause,  es- 
pecially if  a  laceration  has  taken  place.  This  condition  excites 
congestion  of  the  cervix  and  its  lining  membrane.  There  is  a 
hypersecretion  and  an  irritating  discharge.  This  discharge  is 
often  strongly  acid  and  irritating  if  it  comes  from  the  uterus.  It 
ERODES  the  tissues,  mucous  membrane  and  integument  with 
which  it  comes  in  contact,  and  the  cervix  on  inspection  re- 
sembles A  RAW  PIECE  OF  FLESH.  The  local  Congestion  around 
the  impaired  area  soon  develops  into  a  circumscribed  inflamma- 
tion. After  it  exists  for  awhile  the  characteristic  roughened, 
granular  surface  appears.  The  inflammation  may  extend  up- 
ward from  a  vaginitis,  or  downward  from  an  endometritis.  In 
such  cases,  if  not  of  specific  origin,  a  bony  lesion  or  uterine  dis- 
placement are  the  most  important  causes. 

SYMPTOMS.  The  cervix  being  considered  as  a  large  gland, 
the  congestion  produces  a  pathological  secretion  which  is  called 
leucorrhea.  If  there  were  an  arterial  congestion,  there  would 
be  a  hypersecretion,  but  it  would  be  normal  as  to  quality,  but 
being  a  venous  congestion  the  quality  of  the  seretion  is  impaired 
and  the  quantity  increased.  The  normal  secretion  is  clear  and 
viscid,  resembling  the  white  of  an  egg.  If  mucous  corpuscles 
are  present  it  is  an  opaque  white;  if  there  are  pus  corpuscles  it 


EROSION    OF   THE    CERVIX.  337 

becomes  yellowish;  if  blood  is  present  it  becomes  red  in  color. 

Pain  as  in  all  inflammatory  conditions  of  the  uterus,  is  pres- 
ent, either  localized  or  reflected  to  the  back.  It  is  increased  on 
walking  or  in  conditions  in  which  there  is  movement.  Men- 
strual disorders  are  present,  principally  menorrhagia  and  dys- 
menorrhea. On  account  of  the  inflamed  condition  of  the  endo- 
metrium and  the  character  of  the  secretion,  it  being  acid,  steril- 
ity frequently  exists. 

PHYSICAL  SIGNS.  On  vaginal  examination  the  cervix  is 
found  to  be  soft  and  the  os  patulous.  The  eroded  and  rough- 
ened surfaces  can  usually  be  felt.  By  exposing  the  cervix  with 
a  speculum,  the  raw,  eroded  surface  can  be  seen.  Frequently 
an  old  laceration  can  be  seen,  which  is  the  cause  of  the  trouble. 
An  erosion  bleeds  readily  when  touched  with  the  finger  or  an  in- 
strument. Discharge  can  be  seen  exuding  from  the  part,  or  if 
there  is  a  co-existing  endometritis  it  can  be  seen  coming  from 
the  uterine  cavity.  It  is  diagnosed  from  cancer  by  lack  of  odor, 
absence  of  marked  friability  and  the  character  of  the  hemorrhage. 
The  EROSION  IS  LOCALIZED  and  does  not  produce  constitutional 
changes. 

TREATMENT.  The  treatment  resolves  itself  into  a  build- 
ing up  of  the  general  condition  and  relieving  the  congestion  of 
the  cervix.  In  nullipara  it  should  be  applied  to  the  lesions  found 
whi^h  interfere  with  the  pelvic  circulation.  If  the  uterus  is 
displaced,  which  is  the  case  with  a  great  many  patients  suffering 
with  erosion,  it  should  be  corrected  in  order  to  relieve  the  venous 
congestion,  otherwise  local  treatments  will  do  very  little  good. 

In  MULTIPARA.' the  treatment  should  be  similar,  but  in  ad- 
dition, the  laceration,  if  any  exists,  should  be  repaired  if  it  does 
not  heal  after  the  usual  treatment  is  given.  Local  douches  do 
very  little  good.     They  may  relieve  the  condition  temporarily, 


338  DISEASES    OF    WOMEN. 

but  the  after  effect  leaves  them  in  a  worse  condition  than  when 
they  began.  Sometimes  appHcations  of  tannin  and  glycerine 
are  recommended,  but  they  give  only  temporary  relief.  Bis- 
muth is  the  best  antiseptic  to  use  if  one  is  indicated.  Others  ap- 
ply caustics  to  the  eroded  surface,  but  this  seems  to  be  rather  a 
cruel  way  of  treating  such  a  condition.  Deep  work  over  the 
uterus,  and  the  veins  leading  from  it,  with  treatment  applied  to 
the  back  to  increase  the  vaso-motor  tonicity,  is  usually  sufficient 
to  at  least  relieve  if  not  cure  the  erosion.  The  patient  should  be 
kept  as  quiet  as  possible  and  coition  should  be  prohibited. 


ULCERATION   OF  THE   CERVIX.  339 


ULCERATION  OF  THE  CERVIX. 


ULCERATION  OF  THE  CERVIX  is  occasionally  met  with. 
It  is  a  condition  of  advanced  erosion,  that  is,  the  blood  has  stag- 
nated so  long  that  ulcerative  changes  have  set  in.  On  examina- 
tion with  the  speculum,  the  ulcerative  process  can  be  seen. 
Venereal  diseases,  especially  syphilis,  should  be  thought  of  since 
an  ulcer  is  sometimes  formed  on  the  cervix  as  a  result  of  the  in- 
fection. The  discharge  in  ulceration  would  be  of  a  yellowish 
color,  since  pus  from  the  ulcer  is  intermingled  with  it.  In  most 
cases  there  is  a  constitutional  disease  such  as  tuberculosis,  which 
impairs  the  quality  of  the  blood  and  prevents  healing  after  lac- 
eration. The  treatment  should  be  similar  to  that  of  erosion, 
that  is,  the  stagnated  blood  removed  and  fresh  blood  be  pj.it  in  its 
place.  In  addition,  measures  should  be  adopted  to  build  up  the 
general  health  by  the  proper  kind  of  food  and  exercise.  If  the 
ulceration  is  persistent  and  does  not  yield  to  the  ordinary  treat- 
ment to  the  uterus,  abdomen  and  spine,  some  antiseptic  prepara- 
tion should  be  used  directly  on  the  ulcer.  Boracic  acid  or  bis- 
muth can  be  used  advantageously. 


340  DISEASES    OF    "WOMEN. 

INFLAMMATION  OF  THE  UTERUS. 


The  Uterus  is  the  seatof  a  great  many  inflammatory  changes 
both  acute  and  chronic.  Various  authors  divide  these  inflamma- 
tory conditions  into  many  divisions  and  subdivisions,  such  as 
acute  and  chronic  metritis,  both  corporeal  and  cervical,  acute  and 
chronic  endometritis,  and  en  do  cervicitis.  For  our  purpose  the 
general  division  of  inflammation  of  the  uterus  into  metritis  and 
endometritis  is  sufficient.  This  division  is  only  arbitrary,  since  I 
doubt  if  there  is  ever  a  case  of  endometritis  without  it  being 
complicated  with  inflammation  of  the  substance  of  the  uterus  or 
metritis,  or  vice  versa.  Since  both  the  endometrium  and  uterine 
walls  are  supplied  by  the  same  nerves,  blood  vessels  and  lym- 
phatics, consequently  the  same  lesions,  or  other  disturbing  ele- 
ments, affect  both.  Also  the  endometrium  is  in  intimate  rela- 
tion with  the  muscle  fibers  of  the  uterine  walls. 

First,  let  us  consider  what  is  the  condition  in  inflammation 
of  the  uterus.  It  is  an  attempt  or  effort  accompanied  by  red- 
ness, heat,  swelling  and  pain  on  the  part  of  the  organ  to  counter- 
act, excrete  or  destroy  certain  poisonous  or  obnoxious  elements. 
These  poisonous  elements  either  arise  from  within,  or  are  intro- 
duced from  Avithout.  If  introduced  from  without,  the  poison  at 
first  stimulates  for  a  short  time  the  nerve  terminals,  but  soon 
produces  a  weakening,  or  paresis,  of  the  vaso-motor  nerves,  and 
the  blood  flow,  both  arterial  and  venous,  is  lessened  in  rapidity 
or  even  entirely  stopped;  in  other  words,  congestion  or  a  stasis 
results.  The  blood  then  undergoes  changes  which  are  pecu- 
liar to  inflammation,  accompanied  by  exudations  and  de- 
posits, and  changes  in  the  tissues  supplied  by  the  blood  ves- 
sels. Inflammation  as  a  rule,  most  frequently  attacks  the  en- 
dometrium,   which  then  is  called  endometritis.     It  soon  invades 


INFLAMMATION'  OF   THE    UTERUS.  341 

the  neighboring  substance  and  becomes  a  metritis. 

The  poisonous  elements  that  arise  from  within  are  the  re- 
sult of  a  local  stagnation  of  blood.  This  stagnation  results  from 
DISPLACEMENTS  of  the  uterus  and  bowels ;  disease  of  the  adnexa  . 
or  it  follows  exposure  of  the  body  at  a  time  when  the  uterus  is 
physiologically  congested,  as  during  the  menstrual  flow;  also  from 
the  various  lesions  affecting  the  vaso-motor  centers  which  have 
to  do  with  controlling  the  amount  of  blood  in  the  uterus.  Some- 
times there  are  constitutional  diseases  which  are  responsible  for 
the  condition,  but  this  is  rare  in  comparision  with  other  causes 
which  will  be  mentioned  under  the  head  of  causes  of  inflamma- 
tion of  the  uterus. 

Pryor  says  "it  is  an  accepted  fact  that  pelvic  disease  in 
women  is  increasing.  This  is  due  to  three  causes:  The  undoubt- 
ed spread  of  gonorrhea;  the  very  general  dislike  to  childbearing 
and  the  induction  of  abortion,  and  to  unskilled intra-uterine treat- 
ment by  physicians."  The  writer  agrees  to  the  above  state- 
ment, and  would  add  that  the  unskilled  treatment  of  uterine 
diseases  in  general  is  a  very  important  factor  in  the  production 
and  increase  of  pelvic  diseases  in  women. 

THE  BLOOD  SUPPLY  of  the  uterus  is  verj^  abundant.  The 
VEINS  are  large  and  traverse  the  uterus  in  every  direction.  A 
peculiarity  of  the  blood  supply  is  the  disproportion  between 
the  size  of  the  arteries  and  veins,  the  latter  being  the  larger. 
Mayrhofer  says  "When  the  vessels  of  the  uterus  are  injected,  the 
veins  and  arteries  with  different  colored  injection,  one  is  struck 
by  the  great  preponderance  of  veins  over  arteries."  Their  walls 
are  very  thin  so  that  a  very  slight  change  of  pressure  readily  af- 
fects the  blood  stream.  The  blood  is  collected  by  the  uterine  and 
ovarian  veins  and  returned  to  the  inferior  vena  cava,  thence  to 
the  heart.     The  uterine   veins  accompany  the  arteries,  that  is, 


342  risKASES  of  women. 

their  course  at  first  lies  between  the  layers  of  the  broad  ligaments, 
after  which  they  empty  into  the  internal  iliac  veins,  thence  the 
blood  is  carried  by  the  inferior  vena  cava  to  the  heart.  The 
OVARIAN  VEINS,  like  the  arteries,  are  long  and  slender,  hence  the 
greater  liability  of  compression.  The  left  empties  into  the  renal, 
while  the  right  empties  directly  into  the  inferior  vena  cava. 

Respiration  affects  the  uterine  blood  pressure  as  well  as  the 
position  of  the  uterus.  This  has  been  proven  in  different  ways. 
By  placing  the  finger  against  the  cervix  when  the  patient  is  strain- 
ing as  in  coughing,  the  change  in  position  and  consistency  can 
be  readily  noted.  The  analogous  veins  in  the  male,  the  sper- 
matic plexus,  increase  in  size  when  the  intra-abdominal  pressure 
is  increased.  The  author  has  experimented  on  cases  of  vari- 
cocele. The  distention  of  the  veins  could  be  markedly  increased 
by  having  the  patient  hold  his  breath  and  straining  as  if  at  stool. 
The  veins  could  also  be  enlarged  by  the  patient  lifting  or,  in  fact, 
doing  anything  which  caused  an  increase  in  the  intra-abdom- 
inal pressure.  I  recently  had  a  case  in  which  the  patient,  a  young 
lady,  was  groaning  and  breathing  irregularly,  that  is,  she  was 
holding  her  breath  as  long  as  she  could,  then  expelling  it  with  a 
groan.  By  keeping  the  finger  on  the  cervix  it  was  ascertained 
that  the  pulsation  of  the  blood  vessels  varied  with  the  respira- 
tion. The  movements  of  the  uterus  also  varied,  sudden  in- 
spiration DRAWING  IT  UPWARD,  while  holding  the  breath  forced 
it  DOWNWARD.  By  placing  the  patient  in  the  genu-pectoral  posi- 
tion and  admitting  air  into  the  vagina  and  causing  the  patient  to 
breathe  irregularly  and  forcibly,  the  air  was  drawn  in  with  inspira- 
tion and  forced  out  with  expiration,  accompanied  by  the  pecu- 
liar sound  of  escaping  air.  This  goes  to  prove  the  elTect  on  the 
position  of  the  uterus  in  labored  respiration  and  how  easy  it  is  to 
produce  a  congestion  of  it,  which  is  a  preliminary   step   to     in- 


INFLAMMATION    OF  THE    LTERUS.  343 

flammation  of  the  same.  Congestion  can  be  produced  by  vaso- 
motor disturbances.  A  lesion  which  inhibits  and  shuts  off  the 
nerve  force  intended  for  the  blood  vessels  causes  dilatation  of  these 
vessels. 

PARTS  IXFL.\MED.  The  part  most  commonly  inflamed 
is  the  endometrium.  It  is  composed  of  lymphatics,  blood  ves- 
sels, nerves,  glands  and  the  ciliated  columnar  epithelium  which 
lines  the  cavity  of  the  uterus.  The  walls  are  also  frequently 
inflamed,  but  usually  secondarily  to  the  inflammation  of  the 
lining.  They  are  composed  of  a  mucous  layer,  muscular  layers 
and  a  peritoneal  layer.  The  first  is  called  the  endometrium,  the 
second  the  myometrium,  and  the  peritoneal  covering,  the  peri- 
metrium. Between  these  different  layers  are  connective  tissue, 
glands,  etc.  These  glands  form  a  large  part  of  the  substance  of 
the  uterus.  Inflammation  of  the  substance  of  the  uterus,  which 
is  called  metritis,  affects  these  glands,  causing  morbid  secretions. 
Inflammation  of  the  endometrium  is  called  endometritis;  of  the 
perimetrium,  perimetritis  or  local  peritonitis. 

VARIETIES  OF  IXFLAMMATIOX.  The  kind  of  inflamma- 
tion is  named  from  its  intensity,  rapidity  or  according  to  the  part 
of  the  uterus  affected.  The  inflammation  may  be  acute  or  chronic 
simple,  catarrhal  or  parenchymatous,  this  classification  being 
called  the  pathological.  The  classification  into  metritis,  cer- 
vicitis, endocervicitis,  endometritis  perimetritis,  parametritis 
and  peritonitis,  is  called  the  anatomical  classification. 

GENERAL  CAUSES.  The  general  causes  of  inflamma- 
tion are  included  in  two  general  divisions.  First,  traumatism, 
or  where  the  poison  is  introduced  from  without;  or  second,  con- 
gestion, which  is  the  result  of  obstruction  or  vaso-motor  paresis. 
The  first  includes  all  injuries  to  the  endometrium,  cervix  and 
uterine    body  whether  from  parturition,  use  of  instruments  or 


344  DISEASES    OF    WOMEN. 

drugs.  Specific  inflammation  of  venereal  origin  is  also  in- 
cluded under  this  head.  The  second  includes  misplacements, 
bony  lesions,  tumors,  both  of  the  uterus  and  the  neighboring 
structures,  subinvolution,  exposure,  etc. 


ENDOMETRITIS.  345 


ENDOMETRITIS. 


The  ENDOMETRIUM  IS  not  only  a  mucous  membrane  but  is  also 
a  part  of  the  great  lymphatic  system.  This  being  true,  certam 
of  the  general  or  systemic  diseases  affect  it.  In  tuberculosis  it 
becomes  pale  and  anemic;  in  gout  and  malaria  it  congests, 
hence  an  mcreased  menstrual  flow.  Its  function  then  explains 
the  frequency  of  the  uterine  type  of  leucorrhea. 

PATHOLOGY.  In  considering  the  pathology  of  endometri- 
tis the  component  parts  of  the  endometrium  must  be  consider- 
ed, and  following  this,  the  changes  which  each  undergoes.  The 
endometrium  is  composed  of  glands,  arteries,  veins,  lymphatics, 
columnar  and  ciliated  epithelium.  The  blood  vessels  are  en- 
gorged and  soon  the  entire  endometrium,  and  even  the  walls  of 
the  uterus,  becomes  hyperemic.  This  is  so  marked  in  some 
cases  that  a  slight  hemorrhage  takes  place  when  the  uterus  is 
irritated,  as  in  "local  exammation  or  sexual  intercourse.  The 
epithelium,  the  cells  of  which  bemg  thickened  and  prolif- 
erated, becomes  loosened,  disintegrated  and  expelled  with  the 
leucorrheal  discharge.  The  secretions,  in  typical  cases,  become 
muco-purulent ;  this  being  the  result  of  glandular  disturbances. 
The  mucous  membrane  is  often  several  times  as  thick  as  the  nor- 
mal and  becomes  spongy,  soft  and  easily  removed. 

CAUSES.  Endometritis  Is  most  easily  produced  by  an  in- 
strumental mtra-uterine  treatment,  the  sound  being  the  instru- 
ment most  often  used.  If  care  is  not  taken  the  delicate  mucosa 
lining  the  uterine  cavity  will  be  torn  or  injured  by  the  pressure 
exerted  in  replacing  a  displaced  uterus.  Uterine  dilators  or 
tents,  that  are  sometimes  used,  are  also  liable  to  and  usually  do, 


346  DISEASES    OF    WOMEN. 

injure  the  tender  endometrium.  This  leads  to  congestion,  which 
is  followed,  in  most  instances,  by  some  degree  of  inflammation. 
The  uterine  cavity  is  one  that  should  not  be  irritated  or  per- 
mitted to  be  filled  with  air.  This  form  of  inflammation  pro- 
duced by  the  above  is  usually  acute. 

Pessaries  which  have  been  worn  for  some  time  without  re- 
moval, irritate  and  congest  the  vagina  and  cervix,  and  hiflamma- 
tion  follows.  Specific  vaginitis  or  gonorrhea  travels  upward 
from  the  vagina  and  sets  up  an  inflammation  of  the  endometrium 
Sometimes  it  travels  up  the  Fallopian  tubes  into  the  ovaries 
and  peritoneal  cavity.  This  is  a  cause  of  constant  ill  health, 
chronic  local  peritonitis  and  sterility.  Infection  may  come  from 
other  sources  such  as  the  use  of  unclean  instruments  or  dirty 
hands.  Certain  drugs  tend  to  produce  inflammation  of  the 
uterus. 

Peculiar  conditions  of  the  blood  state  tend  to  produce  con- 
gestion of  the  mucous  membrane.  This  not  only  affects  the  endo- 
metrium, but  the  various  other  mucous  membranes  of  the  body. 
This  is  often  found  in_the  exanthemata,  also  in  hemophilia  or 
bleeders  disease. 

Exposure  to  cold  or  getting  wet  during  the  menstrual 
flow,  is  a  common  cause  of  endometritis.  Mental  anxiety  or 
any  sudden  emotion  which  stops  the  menstural  flow  frequently 
produces  inflammation.  I  have  seen  a  great  many  cases  of  in- 
flammation of  the  uterus  which  started  from  over-work  or  ex- 
posure at  the  menstrual  period.  Such  patients  are  tender  over 
the  lower  part  of  the  abdomen  and  have  chronic  menstrual  dis- 
orders. This  menstrual  discharge,  which  should  have  been 
thrown  off,  collects  in  the  uterine  cavity  on  account  of  the  con- 
traction of  the  cervix  which  occludes  the  os.  It  is  partly  ab- 
sorbed and  continues  to  be  a  sovirce  of  constant  irritation  and 
congestion. 


ENDOMETRITIS.  347 

Parturition,  if  accompanied  by  laceration  or  bruising  of 
the  cervix,  is  a  cause  of  inflammation  of  the  uterus,  and  especial- 
ly of  endometritis  in  multipara.  The  inflammation  soon  becomes 
chronic  and  is  the  cause  of  many  complications. 

If  there  are  too  frecjuent  pregnancies  or  abortions  the  uterus 
will  be  found  enlarged  and  inflamed.  This  is  called  subinvolu- 
tion. The  inflammation  will  not  be  confined  to  the  endometrium 
but  invades  the  walls.  Induced  abortion  and  frequent  coitus 
are  other  causes  which  may  first  set  up  a  congestion,  then  an  in- 
flammation of  the  lining  membrane  of  the  uterine  cavity.  In 
either  case  the  os  becomes  and  remains  patulous. 

Displacements  produce  inflammation  by  first  exciting  con- 
gestion. On  account  of  the  obstruction  to  the  circulation  pro- 
duced by  the  twisting  of  the  broad  ligaments  or  by  direct  pressure 
on  the  vessels,  the  blood  undergoes  changes  which  result  in  the 
formation  of  toxic  elements.  If  the  displacement  has  become 
chronic,  there  is  but  little  inflammation,  but  if  it  is  an  acute  or 
recent  one,  there  is  usually  acute  inflammation,  not  only  of  the 
uterus  and  its  lining  but  of  the  neighboring  structures. 

Medicated  pencils  introduced  into  the  os,  excite  inflamma- 
tion of  the  endometrium  whenever  used.  Caustics  and  the  vari- 
ous astringent  applications,  if  used  very  much,  have  a  similar 
effect  on  the  uterus.  They  at  first  stimulate  the  vaso-motor 
nerves,  but  relaxation  and  dilatation  soon  follow  after  the  first 
effects  have  worn  off. 

Passive  congestion  as  the  result  of  some  of  the  above  causes, 
'  or  of  a  mechanical  obstruction,  is  the  most  common  forerunner 
and  cause  of  chronic  endometritis. 

LESIONS.  The  most  common  and  pronounced  bony  le- 
sion is  the  backward  slip  of  the  innominate  bones.     Both  bones. 


348  DISEASES    OF    WOMEN. 

or  only  one,  may  be  slipped  backward,  thus  producing  a  twist  in 
the  entire  pelvis.  This  kind  of  lesion,  more  than  any  other, 
seems  to  affect  the  uterine  circulation.  The  sacrum  may  be 
tilted,  its  most  common  displacement  being  a  forward  rotation  of 
the  upper  part  and  a  posterior  displacement  of  the  lower  part. 
The  lumbar  vertebrae  may  be  displaced,  or  a  rigid  condition  of 
that  part  of  the  spine  may  exist,  or  a  posterior  curve  be  found. 

If  due  to  exposure  the  muscles  along  the  lower  part  of  the 
spinal  column  are  found  to  be  very  much  contractured.  This  is 
frequently  the  beginning  of  the  bony  lesions.  The  tension  ex- 
erted by  a  contracted  muscle  is  considerably  more  than  one 
would  at  first  suppose.  This  finally  results  is  a  slight  bony  dis- 
placement, that  is,  the  bone  is  slowly  pulled  out  of  line.  When 
once  it  is  out,  it  becomes  in  most  cases  a  chronic  condition,  affect- 
ing the  uterine  circulation  and  probably  causing  a  chronic  form 
of  metritis  or.  endometritis. 

To  the  osteopath  these  lesions  are  the  most  important  of 
the  causes  of  endometritis.  With  these  bony  lesions  existing, 
exciting  causes  readily  act.  Without  correcting  these  lesions 
permanent  cures  cannot  be  made,  although  temporary  relief 
may  be  given.  Cases  of  membranous  dysmenorrhea,  which  is 
only  one  of  the  many  forms  of  this  inflammation,  can  be  cured  by 
osteopathic  methods  even  after  other  methods  have  failed.  This 
has  been  demonstrated  a  great,  many  times  in  our  own  practice. 
In  such  cases  a  bony  lesion  was  found,  the  subluxated  innominate 
being  the  most  common,  and  after  correction  the  symptoms  dis- 
appeared. 

SYMPTOMS.  The  symptoms  of  an  endometritis  depend 
upon  the  degree  of  inflammation.  The  acute  form  is  accom- 
panied by  the  usual  indication  of  inflammation,  such  as  heat, 
redness,  swelling,    pain  and  perversion  of  function.     The  abdo- 


ENDOMETRITIS.  349 

MEN  is  tense,  tender  and  in  most  cases  tympanitic.  The  neigh- 
boring organs  are  affected,  menstrual  function  is  deranged,  and 
an  acute  pain  and  tenderness  exists  in  the  pelvic  region.  There 
will  be  symptoms  of  peritonitis,  especially  in  cases  produced  by 
exposure  during  the  menstrual  flow. 

The  MOST  IMPORTANT  SYMPTOM  of  chronic  endometritis  is 
PAINFUL  MENSTRUATION.  The  uterus  contracts  to  expel  the 
menstrual  flow.  If  the  endometrium  is  raw^  and  inflamed,  and 
it  is  in  endometritis,  it  is  like  clenching  the  hand  when  the  palm 
is  raw  and  eroded,  both  of  which  result  in  severe  pain,  and  the 
greater  the  contraction  the  worse  the  pain. 

Again,  the  irritated  endometrium  is  conducive  to  uterine 
contraction.  The  introduction  of  any  instrument  or  anything 
into  the  uterine  cavity  produces  contraction  of  the  uterus,  and 
especially  so  if  the  endometrium  is  in  a  state  of  irritation,  the 
uterus  responding  to  a  lesser  stimulus  than  it  does  when  normal. 
On  account  of  the  above  mentioned  conditions  any  shock,  ex- 
posure, injury  or  lesion  will  more  readily  cause  uterine  contrac- 
tion and  dysmenorrhea.  This  explains  post-menstrual  and 
INTER-MENSTRUAL  pain,  that  is,  a  lesion  is  present  which,  coupled 
with  some  exciting  cause,  results  in  increased  peristalsis  of  the 
uterus. 

The  AMOUNT  OF  MENSTRUAL  PAIN  depends  upon  the  degree 
of  inflammation.  If  the  blood  has  been  retained  in  the  uterus 
even  for  a  short  time,  it  becomes  clotted  and  then  the  process  of 
expulsion  is  similar  to  that  of  labor.  In  fact,  if  there  is  clotted 
blood  discharged  at  the  menstrual  period  it  indicates  inflammation 
of  the  endometrium  and  is  one  of  the  best  symptoms  of  the  same. 

Nearly  all  uterine  pains  at  the  menstrual  period,  come  from 
inflammation  of  the  endometrium.  Flexion  rarely  produces 
dysmenorrhea    unless    accompanied    by   inflammation.     Reflex 


350  DISEASES    OF    WOMEX. 

troubles  at  that  time  are  rare  unless  there  is  an  endometritis. 

Membranous  dysmenorrhea  is  a  very  striking  symptom 
or  example  of  endometritis.  The  entire  lining  of  the  cavity  of 
the  uterus  is  loosened  and  cast  off  en  masse,  this  loosening  of 
the  endometrium  being  the  result  of  changes  dependent  on  endo- 
metritis. The  pain  is  due  partly  to  the  inflammation  and  partly 
to  the  presence  of  the  membrane,  both  of  which  are  likely  to  set 
up  an  extreme  contraction  of  the  uterus  in  its  efforts  to  expel  or 
overcome  the  foreign  body  or  the  irritation. 

In  gonorrheal  endometritis,  the  onset  is  sudden,  with 
fever,  uterine  cramps  and  general  pelvic  pain,  soon  followed  by  a 
discharge  which  rapidly  becomes  purulent.  The  inflammatory 
process  soon  extends  to  the  Fallopian  tubes,  ovaries  and  pelvic 
peritoneum.  The  vulva  and  vagina  show  signs  of  inflammation. 
The  meatus  has  a  dark  red  appearance;  the  uterus  is  very  ten- 
der and  the  gentlest  manipulation  causes  marked  pain.  It  en- 
larges and  the  connective  tissues  about  it  thicken. 

The  lymphatic  glands  increase  in  size  and  become  very 
tender.  The  ovarian  tenderness  increases  while  the  endome- 
tritis becomes  less  severe.  A  chronic  discharge  is  establish- 
ed, w^hich  increases  in  amount  whenever  uterine  congestion  is 
increased,  as  at  the  menstrual  period.  The  discharge  contains 
pus  and  is  sometimes  very  irritating. 

As  a  result  of  the  congested  mucous  membrane,  the  secre- 
tions become  abnormal.  Instead  of  the  uterine  secretion  be- 
ing watery  in  character  it  becomes  whitish,  milky  or  blood 
tinged.  In  other  cases  it  is  purulent  on  account  of  its  retention 
and  accumulation  in  the  uterine  cavity.  The  discharge  is  fre- 
quently strongly  aciA  in  character  and  sets  up  a  pruritus.  Back- 
aches and  various  other  reflex  aches  are  very  common.  Endo- 
metritis is  the  most  common  cause  of  reflex  pains  or  aches. 


ENDOMETRITIS.  351 

The  congested  condition  which  accompanies  the  inflamma- 
tion increases  the  weight  of  the  uterus,  thus  producing  pressure 
on  some  parts  and  traction  on  other  parts.  This  congestion  often 
leads  to  hemorrhage  in  the  form  of  a  menorrhagia,  or  even  a 
metrorrhagia.  The  effects  depend  on  the  amount  and  quality 
of  blood  lost.  Anemia,  indigestion  and  general  weakness  most 
frequently  follow. 

The    DISTURBANCE   OF  THE   UTERINE   CIRCULATION   afifects   the 

PELVIC  NERVOUS  system.  The  various  reflexes  are  the  re- 
sult. The  limbs  are  heavy  and  the  small  of  the  back  weak.  If 
a  patient  were  to  come  to  you  suffering  with  a  weak  back,  that  is 
if  she  complained  of  an  ache,  or  an  acute  pain,  suspect  an  inflam- 
mation of  the  uterus,  either  an  endometritis  or  a  metritis,  the 
former  being  the  more  common.  This  backache  as  men- 
tioned above  may  be  the  result  of  a  lesion,  sexual  excesses, 
laceration  or  displacement.  The  degree  and  character  of  the 
pain  in  uterine  displacements  depend  more  on  the  amount  of 
inflammation,  that  is  endometritis  and  metritis,  than  all  other 
THINGS  COMBINED.  A  utCFUs  free  from  inflammation  is  in  most 
cases,  a  fairly  normal  one  regardless  of  its  position,  and  if  disease 
exists  one  should  look  elsewhere  than  in  the  uterus  for  the  cause. 

When  the  uterus  or. part  of  it  is  inflamed  the  digestive 
tract  is  usually  weakened.  Digestion  is  impaired  and  appetite 
lost.  Frontal  headaches  are  sometimes  found  which  are  reflex 
from  the  stomach.  Sometimes  nausea  and  vomiting  exist,  which 
may  lead  one  to  suspect  pregnancy.  I  recently  had  a  case  of 
slight  endometritis  complicated  by  morning  nausea  and  vomit- 
ing, which  was  mistaken  for  pregnancy.  Local  examination 
cleared  up   the   diagnosis. 

Sterility  is  almost  a  constant  symptom.  The  acid  leu- 
corrheal  secretions  from  the  uterus  conteract  and  kill  the  sper- 


352  DISEASES   OF    WOMEN. 

matozoa.  Sometimes  impregnation  does  take  place,  but  if  it 
does  the  woman  seldom  carries  to  term.  The  endometrium  be- 
ing congested  and  inflamed  furnishes  an  imperfect  nidus  for  at- 
tachment of  the  impregnated  ovum.  In  some  cases  the  fetus 
is  carried  to  term,  but  this  is  the  exception  to  the  rule.  To  make 
a  resume,  the  symptoms  are  dysmenorrhea,  leucorrhea,  reflex 
aches,  digestive  disturbances,  nervous  changes  such  as  hysteria 
and  usually  sterility. 

PHYSICAL  SIGNS.  Tenderness  is  elicited  on  pressure  over 
the  lower  part  of  the  abdomen.  This  is  one  of  the  best  objec- 
tive indications  of  an  inflamed  uterus,  whether  metritis  or  endo- 
metritis. In  such  cases  care  should  be  taken  not  to  mistake 
cystitis,  for  an  inflammation  of  the  uterus. 

On  local  examination  the  cervix  is  found  to  be  large  and 
SOFT,  while  the  os  is  patulous.  Sometimes  the  endometrium  is 
everted  and  can  be  felt.  On  examination  with  the  speculum, 
the  inflamed  surface  can  be  seen  if  it  involves  the  cervical  endo- 
metrium or  if  the  case  is  not  one  of  too  long  standing.  The  cer- 
vical endometrium  is  raw  looking,  and  the  leucorrheal  discharges 
are  seen  emanating  from  the  external  os.  The  least  movement 
of,  or  pressure  on  the  uterus,  produces  pain.  There  is  painful 
coition  or  dyspareunia  if  the  inflammation  is  acute.  If  the  sound 
is  introduced  it  becomes  tinged  with  blood.  It  excites  pain, 
sometimes  spasms,  in  which  cases  it  should  not  be  used.  Pres- 
sure on  the  uterus  through  the  fornices,  per  rectum  or  through 
the  abdominal  wall,  causes  pain. 

DIAGNOSIS.  In  laceration  of  the  cervix  there  are  similar 
subjective  symptoms,  but  the  physical  examination  reveals  radiat- 
ing fissures  by  which  it  is  definitely  diagnosed.  It  is  diagnosed 
from  cancer  by  absence  of  the  usual  signs  of  cancer,  such  as  fri- 
ability,  sudden   hemorrhage,   fetid  odor  and   watery   discharge 


ENDOMETRITIS.  353 

If  in  doubt,  a  microscopical  examination  should  be  made.  There 
are  various  conditions,  such  as  granular  erosion,  ulceration  and 
the  above  mentioned  diseases,  which  are  accompanied  by  an  endo- 
metritis but  have  in  addition  their  own  peculiar  symptoms. 

PROGNOSIS.  The  prognosis,  as  in  other  inflammatory  dis- 
eases, depends  upon  the  length  of  standing,  causes,  and  the  in- 
dividual case,  each  one  being  different.  In  most  cases  it  is  good. 
If  venereal  disease  is  present  producing  it,  the  prognosis  is  not 
so  good,  since  the  disease,  when  once  in  the  uterus  or  Fallopian 
tubes,  is  very  hard  to  eradicate.  If  due  to  a  laceration  and  the 
patient  otherwise  in  good  health,  it  is  favorable.  If  the  patient 
is  pale,  anemic,  the  blood  thin,  and  there  is  much  weakness,  the 
prognosis,  as  to  a  cure  is  unfavorable,  but  for  relief  it  is  favor- 
able. Under  osteopathic  treatment  the  prognosis  is  a  great  deal 
more  favorable  than  under  any  other,  and  it  is  the  exception  to 
meet  with  a  case  that  cannot  at  least  be  helped  if  not  entirely 
cured.  Cases  have  been  cured  at  the  Infirmary  at  Kirksville, 
in  which  the  inflammation  was  so  marked  that  the  entire  endo- 
metrium was  thrown  off  en  masse  every  few  days,  that  is,  just 
as  often  as  it  was  formed. 

TREATMENT.  The  treatment  of  endometritis  depends  on 
the  cause  producing  it  and  the  stage  of  inflammation.  The  ob- 
ject to  be  attained  is  to  relieve  the  congestion  and  to  flush  the 
affected  parts  with  pure  blood.  If  a  bony  lesion  is  found  it 
should  be  corrected  as  soon  as  possible,  since  a  cure  depends  on 
it.  If  it  is  ascertained  that  the  cause  is  a  displacement  of  the 
uterus  it  should  also  be  corrected,  for  the  uterus  will  remain 
congested  almost  as  long  as  it  is  malposed.  If  a  laceration  is 
the  cause,  treatment  should  be  directed  to  it  to  get  union  of  the 
two  edges,  or  at  least  to  remove  the  congestion. 

The  method  most  in  vogue    among  physicians  is  curettage 


354  DISEASES   OF   WOMEN. 

of  the  uterus.  A  dull  or  sharp  instrument  is  introduced  into  the 
cavity  and  the  endometrium  scraped  away.  It  seems  to  me  like 
a  barbarous  method  by  which  to  torture  a  patient,  and  I  have 
the  first  case  to  see  in  which  any  permanent  good  resulted.  Pa- 
tient after  patient  has  come  to  me  for  treatment  for  this  disease, 
that  has  had  the  operation  performed  one  or  more  times.  The 
THEORY  IS  that  a  new  endometrium  which  is  healthy  will  be 
formed.      If  the  nourishment  were  shut  off  from  the  old 

ENDOMETRIUM  SO  THAT  THERE  WAS  CONGESTION  AND  INFLAMMA- 
TION or  DISTURBANCE  IN  NUTRITION,  how  couM  a  healthy  endo- 
metrium be  formed  without  first  correcting  the  primary  cause  of 
the  trouble.  It  is  treating  the  effect  and  leaving  the  cause  alone. 
Suppose  a  bony  lesion,  and  by  the  way  it  is  the  most  important 
and  common  cause  found,  is  producing  the  trouble;  the  uterus 
might  be  curetted  every  month  until  the  patient  reaches  the 
menopause,  but  still  the  cause  exists  and  the  endometrium  will 
be  diseased.  Nostrom  in  speaking  of  curettage  in  endometri- 
tis says:  "I  wonder  how  a  procedure  like  this  can  have  any  in- 
fluence on  the  inflammation  of  the  uterine  parenchyma,  which 
always  co-exists  to  a  greater  or  lesser  degree  with  the  endome- 
tritis, when  the  latter  has  been  of  long  standing.  It  appears  to 
me  as  if,  when  the  mucous  membrane  is  regenerated  and  connec- 
tion between  the  endometrium  and  parenchyma  is  re-establish- 
ed, the  previous  morbid  symptoms  would  easily  return,  since  they 
have  the  same  blood,  lymphatic  and  nerve  supply.  This  is  just 
what  frequently  happens  and  I  attribute  to  this  the  frequent  re- 
lapses. I  have  seen  one,  two  and  even  three  relapses  follow 
curettage  done  by  the  most  skillful  gynecologists." 

He  further  says:  "Besides,  to  pretend  to  cure  cervical 
catarrh  by  curettage  seems  to  me  to  be  an  illusion  which  the  most 
primitive  anatomical  knowledge    will  be  sufficient  to  destroy." 


ENDOMETRITIS.  doo 

This  Swedish  author  certainly  voices  the  sentiment  of  most  os- 
teopaths on  the  above  subject.  Diseases  must  be  treated  from 
the  anatomical  standpoint  if  a  cure  is  expected.  Treatment  ap- 
plied to  an  effect,  and  the  use  of  a  curette  in  endometritis  is  one, 
will  not  remove  the  cause. 

This  bony  lesion,  usually  a  slipped  innominate,  shuts  off  part 
of  the  nerve  force  which  should  go  to  the  uterus.  The  circula- 
tion is  slowed  and  degenerative  changes  take  place  in  the  blood. 
By  the  stimulation  which  results  from  a  correction  of  these 
lesions,  both  bony  and  muscular,  the  blood  pressure  is  raised 
and  the  old  stagnated  blood  forced  out  and  replaced  by  new. 
This  is  the  object  we  want  to  attain. 

Again,  manipulate  over  the  abdomen  to  lift  up  the  intes- 
tines, raise  the  diaphragm  and  remove  the  pressure  from  the 
veins;  this  tends  to  relieve  the  congestion  accompanying  the  en- 
dometritis. Since  endometritis  is  preceded  by  congestion,  in 
most  cases  the  above  becomes  a  very  important  treatment. 
Rest  should  be  required  and  the  patient  not  allowed  to  remain 
long  on  her  feet. 

Prophylactic  treatment  should  be  given  in  cases  of  repeated 
endometritis.  The  patient  should  guard  against  exposure  and 
excitement  during  the  menstrual  flow.  Hot  vaginal  douches  are 
commonly  advocated  but  I  think  they  are  of  little  use  either  as  a 
curative  or  prophylactic  measure. 

Recently  the  writer  treated  a  case  of  chronic  endometritis 
coupled  with  membranous  dysmenorrhea,  in  which  a  promi- 
nent physician  had  advised  a  daily  irrigation  of  the  vagina  in 
which  forty  gallons  of  hot  water  were  used  at  a  sitting.  This 
was  repeated  daily  for  over  a  month.  The  patient  survived  and 
the  inflammation  was  partly  relieved  but  the  pelvic  floor  and 
vaginal  walls  were  greatly  weakened.     The  mucous  membrane 


356  DISEASES    OF   WOMEN. 

seemed  to  be  "washed  out"  and  it  took  several  months'  treat- 
ment to  restore  tone  and  normal  secretion.  Various  medicated 
preparations  are  advised,  but  they  usually  irritate  instead  of 
alleviate. 

In  the  gonorrheal  type  of  endometritis  little  can  be  accom- 
plished by  antiseptic  douches.  This  form  of  endometritis  is  very 
hard  to  cure;  in  fact,  it  is  regarded  by  most  physicians  as  prac- 
tically incurable.  From  an  osteopathic  view  point,  the  same 
kind  of  a  treatment  is  given  in  this  as  in  the  other  types  of  uterine 
inflammation,  that  is,  one  directed  to  restoring  normal  circula- 
tion through  the  uterus.  This  is  accomplished  in  many  cases 
by  correcting  lesions,  whether  bony,  muscular  or  visceral.  In 
other  words,  perfect  adjustment  is  attempted  which,  if  secured, 
will  result  in  the  cure  of  any  disease  unless  death  of  too  great 
amount  of  tissue  has  taken  place.  In  an  adjusted  body  the 
LLooD  IS  pure,  hence  germicidal,  and  as  a  result,  the  gonococci 
in  the  uterine  cavity  will  be  destroyed,  if  they  come  in  contact 
with  it. 


METRITIS.  357 


METRITIS. 


Metritis  is  an  inflammation  of  the  parenchyma  of  the 
uterus.  It  is  usually  found  associated  with  endometritis, 
sometimes  as  a  cause,  but  more  frequently  as  a  result.  It  is  also 
found  in  connection  with  ovarian  troubles  and  other  pelvic  in- 
flammatory conditions.  Perimetritis  is  frequently  found  as 
a  complication,  the  patient  complaining  of  tenderness  and  pain 
over  the  lower  part  of  the  abdominal  wall.  Adhesions,  joining 
the  uterus  to  some  neighboring  structure,  are  present  as  a  result 
of  the  exudate. 

CAUSES.  Ixflammatiox  of  the  uterine  walls  is  caused 
by  the  same  factors  that  enter  into  the  causation  of  inflammation 
of  the  endometrium,  on  account  of  the  relation  of  the  endome- 
trium to  the  walls  of  the  uterus.  Metritis  always  compli- 
cates endometritis,  and  in  many  cases  the  latter  is  the  primary 
inflammation  of  the  uterus.  It  occurs  more  frequently  as  a  se- 
quel to  parturition  than  from  any  other  cause.  While  the  uterus 
is  enlarged,  it  is  congested  and  is  subject  to  displacement  and 
injuries.  Some  writers  describe  subinvolution  as  a  form  of 
chronic  metritis.  It  is  present  in  subinvolution,  possibly  as  an 
effect,  not  as  a  cause.  Any  cause  which  increases  the  con- 
gestion of  the  uterus  w^ill  produce  inflammation  of  its  sub- 
stance. 

The  bony  lesions  are  the  most  important  causes  of  this  form 
of  uterine  disease.  These  lesions  are  commonly  present  in  the 
lumbar  region;  also  the  innominata  are  often  found  displaced. 
The  vaso-motor  centers  for  the  uterus,  also  the  centers  for  the 
tone  of  the  uterine  muscle  fibers,  are  affected  by  these  lesions. 


358  disease's  of  women. 

Congestion  of  the  uterus  follows  a  disturbance  of  these  vaso- 
motor centers  since  the  usual  effect  of  the  lesion  on  the  center, 
is  that  of  inhibition.  In  chronic  cases  relaxation  follows  disturb- 
ance of  the  center  for  tone  of  muscles.  Cramping  of  the  uterus 
usually  occurs  as  an  immediate  or  primary  effect.  Since  a  cer- 
tain amount  of  uterine  contraction  or  tone  is  necessary  to  a  nor- 
mal uterine  circulation,  a  vascular  effect  is  produced  by  a  dis- 
turbance of  the  center  for  tone.  Enlargement,  with  venous 
engorgement,  follows  these  disturbances  which  lead  to  chronic 
metritis. 

If  the  patient  has  led  a  life  involving  standing  on  the  feet 
a  great  deal  of  the  time,  the  sacrum  (lower  part)  is  thrown  back- 
ward since  the  weight  of  the  body  is  supported  by  the  upper  part 
of  the  sacrum.  If  she  leads  a  sedentary  life  and  is  not  on  her 
feet  very  much,  or  there  has  been  no  jarring  or  straining  of  the 
pelvis  while  in  the  erect  posture,  the  lower  part  of  the  sacrum 
may  be  thrown  forward;  but  this  is  rare  in  comparison  with  the 
other  forms  of  displacement.  If  there  is  a  kyphosis  of  the  lum- 
bar vertebrae  the  upper  part  of  the  sacrum  will  be  drawn,  or 
rather  forced,  backward  for  compensation.  Sedentary  occupa- 
tions TEND  TO  produce  A  POSTERIOR  LUMBAR  CURVE  WHICH  IS  FOL- 
LOWED BY  A  STRAIGHT  SACRUM.  Displacements  of  the  sacrum  af- 
fect the  different  muscles  attached  to  these  bones,  especially  the 
quadratus  lumborum,  thus  producing  traction  on  the  twelfth  rib 

and  TENDERNESS  IN  THE  SMALL  OF  THE  BACK. 

The  various  causes  mentioned  under  endometritis  will 
also  prdouce  this  condition,  since  both  metritis  and  endome- 
tritis follow  any  condition  resulting  in  uterine  congestion.  Ex- 
posure during  menstruation,  injury,  childbirth,  constipation, 
enteroptosis,  strain  of  the  back,  displacement  of  the  uterus,  ab- 
dominal and    pelvic  growths,   infection,   stem  pessaries,   intra- 


METRITIS.  359 

uterine  medication,  excessive  venery  and  the  various  devices 
used  to  prevent  pregnancy,  and  the  boxy  lesions  mentioned 
above  are  the  most  common  causes. 

A  great  many  of  these  exciting  causes  depend  upon  the  pre- 
disposing weakness  produced  by  these  bony  lesions.  The  most 
important  of  these  causes,  judging  from  my  own  practice,  are 
exposure  during  menstruation  and  acute  uterine  displacement. 
If  the  patient  becomes  chilled  during  the  menstrual  period,  the 
flow  may  be  lessened  or  stopped;  the  uterus  increases  in  size,  fill- 
ing the  true  pelvic  cavity;  fever  follows  and  peritonitis  of  vary- 
ing degrees  is  present  in  all  cases.  The  uterus  was  physiologically 
congested,  the  retention  or  lessening  of  the  flow  changing  it  to  a 
pathological  congestion,  which  always  precedes  inflammation. 

A  sudden  prolapsus  produces  a  similar  effect ;  first  the  conges- 
tion, then  swelling  or  enlargement  of  the  uterus  followed  by  in- 
flammation. 

These  causes,  however,  are  not  always  active  unless  there 
are  predisposing  conditions  which  weaken  the  pelvic  organs. 
These  predisposing  causes  are  lesions,  enteroptosis  from  stand- 
ing, and  subinvolution  from  improper  care  at  or  just  after  labor. 

In  very  chronic  cases  of  metritis,  after  the  acute  symptoms 
such  as  peritonitis,  fever  and  acute  congestion  have  diminished 
or  disappeared,  the  uterus  becomes  hardened  or  sclerosed;  there 
is  an  increase  in  the  amount  of  connective  tissue  between  the  mus- 
cle fibers;  a  thickening  of  the  coats  of  the  vessels,  especially  the 
arteries;  and  uterus  becomes  almost  as  hard  as  cartilage. 
This  is  the  result  of  inflammation,  it  terminating  in  such  cases 
in  formation  of  scar  tisue. 

SYMPTOMS.  In  acute  metritis  there  may  be  a  rigor, 
fever,  a  distended,  swollen  condition  of  the  abdomen  with  sharp 
pain  and  tenderness.     On  account  of  it  affecting  the  peritoneum, 


360  DISEASES    OF    WOMEN. 

the  symptoms  of  peritonitis  are  present.  The  pressure  pains 
are  very  severe;  the  backache  is  almost  unbearable;  tenes- 
mus of  the  rectum  with  hemorrhoids  occurs  in  most  cases;  the 
UTERUS  ITSELF  ACHES  as  does  an  edematous  leg  or  testicle,  on 
account  of  the  varicose  condition  of  its  veins;  there  is  persist- 
ent PELVIC  pain  with  extreme  abdominal  tenderness,  this 
being  most  marked  in  the  iliac  fossae;  and  the  secretions  are  in- 
creased and  are  of  a  very  foul  odor. 

In  chronic  cases,  menstruation  is  affected,  usually  painful 
and  increased  in  amount  and  the  menstrual  discharge  clotted. 
Secretions  are  deranged,  leucorrhea  being  usually  present. 
There  is  a  constant  sense  of  weight,  dragging  sensation  of 
the  limbs,  chronic  backache  and  headache.  Hysteria  in  its 
various  forms  may  be  present.  Functional  heart  troubles  are 
common,  the  patient  fainting  on  the  slightest  provocation. 
Nervous  dyspepsia  exists,  and,  in  short,  nearly  all  the  reflexes 
depending  on  inflammation  of  the  uterus.  A  displaced  uterus 
causes  the  greatest  trouble  when  congestion  and  inflamma- 
tion accompany  it.  I  have  relieved  various  reflex  pains  and 
aches  supposed  to  have  been  due  to  a  displacement,  by  partial- 
ly relieving  the  inflammation  and  not  correcting  the  displaced 
uterus.  It  is  best  to  correct  the  displacement  if  it  can  be  done, 
but  in  a  great  many  cases  it  can  not  be  done  and  you  will  have  to 
depend  for  relief  of  the  symptoms  upon  the  treatment  to  relieve 
the  congestion.  Of  course  all  the  inflammation  and  congestion 
in  every  case  can  not  be  removed  while  the  uterus  is  still  dis- 
placed, but  a  large  per  cent,  can,  and  this  gives  wonderful  relief. 

A  great  many  women  have  displacements  which  give  them 
little  or  no  trouble  because  there  is  no  congestion  or  inflammation 
attending  them.  As  mentioned  above,  the  amount  of  pain,  as 
well    as  the  number  and  intensity  of  the  reflexes,  is  determined 


METRITIS.  361 

by  the  character  and  degree  of  the  pelvic  inflammation.  As 
stated  before,  a  uterus  free  from  iNFLAr^niATiON,  that  is.  one 
not  tender  on  palpation,  is  about  as  normal  as  it  is  possible  for 
it  to  be,  regardless  of  its  position. 

Metritis  then,  is  the  most  important  of  uterine  affections 
and  merits  most  attention.  The  most  important  sign  in  the 
diagnosis  of  metritis  is,  the  tenderness  of  the  uterus  as  elicited  by 
abdominal  and  vaginal  palpation.  Pressure  just  above  the 
symphysis  pubis,  causes  an  acute  or  dull  pain,  it  depending  on 
the  amount  and  degree  of  inflammation  of  the  uterus.  As  in  endo- 
metritis, cystitis  should  be  kept  in  mind  since  pain  is  produced 
on  pressure  just  above  the  symphysis,  if  it  is  present. 

On  vaginal  examination  the  os  is  found  patulous,  the  cervix 
soft  and  enlarged.  In  cervical  metritis,  digital  examination  re- 
veals a  SOFTENED  area  just  internal  to  an  apparently  car- 
tilaginous rim,  which  condition  is  possibly  due  to  cystic  degen- 
eration. Sometimes  there  is  a  soft  velvety  covering  on  this 
hardened  rim,  and  shot-like  bodies,  as  in  laceration,  are  found 
embedded  in  the  cervix.  These  bodies  can  be  seen  on  examination 
with  the  speculum  and   give  the  cervix  a  wart-like  appearance. 

If  the  case  is  chronic,  the  vaginal  walls  are  soft  and  weak. 
A  slimy  discharge  that  is  a  vaginal  leucorrhea  is  present,  cover- 
ing them. 

On  bimanual  examination  the  entire  uterus  is  found  en- 
larged and  tender.  Sometimes  this  examination  can  not  be 
made  on  account  of  the  pain  it  causes.  The  uterus  is  usually 
RETROVERTED  Or  retro flexed,  more  frequently  a  mild  form  of  the 
latter.  The  corpus,  weakened  by  inflammation,  allows  the  fun- 
dus to  be  forced  either  forward  or  backward  according  to  the 
forces  acting  upon  it,  since  it  is  the  support  of  the  fundus.  Ster- 
ility is  a  result,  if  the  condition  has  existed  for  some  time. 


362  DISEASES    OF    WOMEN. 

PROGNOSIS.  The  prognosis  is  favorable  in  most  cases. 
Upon  the  relieving  or  cure  of  this  condition  depends  the  cure 
of  most  cases  of  dysmenorrhea,  reflex  troubles,  backaches,  uterine 
form  of  leucorrhea  and  the  various  local  pelvic  pains  that  are  so 
common  in  the  female.  If  the  condition  is  very  chronic,  do  not 
promise  the  patient  a  cure  in  a  given  length  of  time.  If  the 
back  is  rigid,  and  the  bony  displacements  fixed  and  immovable, 
it  will  take  time  to  restore  them  to  the  normal  condition.  Re- 
lief can  be  given  in  a  short  time  if  there  is  acute  pain. 

TREATMENT.  The  treatment  is  similar  to  that  given  under 
endometritis.  The  bony  lesions  should  be  corrected;  in  short, 
any  lesion  interfering  with  the  normal  nervous  connection  should 
be  removed.  This  is  accomplished  by  correcting  the  bony 
lesion  or  by  working  directly  over  the  structures  and  viscera. 
Obstructions  to  the  proper  return  of  blood  to  the  heart  should 
be  removed.  These  can  be  removed  by  work  directed  to  the 
intestines,  lifting  them  out  of  the  true  pelvis  and  working  direct- 
ly over  the  deep  veins  of  the  abdomen.  Advise  the  patient  to 
keep  off  her  feet  as  much  as  possible  and  to  be  out  in  the  open  air 
a  great  deal.  The  fresh  air  is  exhilarating  and  builds  up  the 
quality  of  the  blood,  which  is  very  helpful.  Hermann  says  that 
there  is  no  drug  that  has  any  specific  effect  upon  subinvolution 
or  chronic  metritis. 

The  UTERINE  displacements  should  be  corrected,  since  the 
congestion  depends  to  a  certain  extent  upon  the  twisting  of  the 
broad  ligaments  which  impinges  the  blood  vessels.  Massage 
of  the  uterus  is  highly  recommended  by  some  osteopaths.  If 
properly  given  it  is  quite  helpful  in  restoring  normal  circulation 
through  the  uterus,  and  tone  to  its  ligaments.  A  quantity  of 
retained  secretions  can  be  worked  out  of  the  uterus  by  carefully 
manipulating  it. 


METRITIS.  363 

The  patient  shovikl  avoid  exposure  during  the  monthly  sick- 
ness. There  is  an  increased  congestion  at  this  time,  consequent- 
ly all  the  symptoms  of  metritis  are  aggravated.  The  genu- 
PECTORAL  position  is  helpful  and  should  be  taken  at  least  once 
each  day  since  the  uterus  partially  empties  itself  of  blood  while 
the  patient  is  in  this  position.  Abdominal  treatments  are  best 
given  while  in  this  position,  since  gentle  work  over  the  abdo- 
men helps  the  return  circulation  by  relieving  the  pressure  of  the 
intestines. 

Attention  to  the  action  of  the  bowels  is  important.  A  dis- 
tended rectum  and  sigmoid  flexure  favor  a  localized  venous  con- 
gestion and  are  partly  to  blame  for  some  of  the  varied  disturb- 
ances which  are  found  in  connection  with  uterine  diseases.  The 
practice  of  using  w'arm  water  in  vaginal  douches  and  the  pro- 
duction of  scarification  of  the  uterus  are  not  to  be  recommended. 
Depletion  by  means  of  leeches  and  counter-irritants  are  not  in- 
dicated, and  are  productive  of  more  harm  than  good. 


364  DISEASES    OF    WOMEN. 


ACUTE  INFLAMMATION  OF  THE  UTERUS. 


ACUTE  INFLAMMATION  OF  THE  UTERUS  is  character- 
ized by  fever,  distention  of  the  abdomen,  cessation  of  secretions 
at  first,  and  pain,  either  local  or  reflex,  usually  referred  to  the 
stomach,  liver,  or  small  intestines.  The  patient  lies  with  the 
limbs  drawn  up,  the  abdominal  muscles  being  very  tense 
and  very  much  contracted.  The  appetite  is  lost  and  the 
stomach  deranged.  On  local  examination  the  vaginal  walls 
are  found  to  be  very  hot  to  the  touch.  The  uterus  is  very 
TENDER,  FIXED  and  the  ligaments  tense.  Displacement,  which 
has  come  on  suddenly,  is  usually  found,  and  is  in  most  cases  a 
prolapsus,  resulting  from  running  or  a  fall.  Immediate  conges- 
tion ensues,  pelvic  pain  becomes  intense  and  within  a  few  hours 
the  signs  of  inflammation  are  apparent.  In  many  of  these  cases, 
a  chronic  uterine  displacement  was  primary;  the  exciting  cause 
exaggerating  the  malposition.  In  other  cases  the  acute  metri- 
tis is  due  to  specific  infection  which  traveled  from  the  vagina 
to  the  uterus.  In  such  cases  the  vaginal  symptoms  of  gonorrhea 
are  present  in  addition  to  the  inflammation  of  the  uterus  and  its 
adnexa.  By  correcting  the  displaced  uterus  and  relaxing  the 
muscles  over  the  lower  lumbar  and  sacral  regions,  the  fever  can 
be  reduced  and  the  inflammation  relieved.  The  writer  has  cured 
most  of  his  cases  of  acute  inflammation  of  the  uterus  which  were 
brought  on  by  sudden  displacements,  by  first  replacing  the 
UTERUS,  then  placing  the  patient  in  the  genu-pectoral  position, 
and  while  in  that  position,  working  out  the  congestion. 

The  other  important  cause  of  acute  metritis  is  exposure 
DURING  the  menstrual  flow.     It  may  be  only  a  chilling  of   the 


ACUTE    INFLAMMATION   OF   THE    UTERUS.  365 

body  but  the  quantity  of  the  flow  is  affected.  Anything  that 
results  in  catching  cold  at  that  time  may  stop  the  flow  and  pro- 
duce inflammation.  If  the  flow"  is  suddenly  checked  inflamma- 
tion is  almost  sure  to  follow. 

In  the  treatment  of  acute  metritis  the  use  of  hydroscopic 
agents,  such  as  glycerine  tampons,  is  advised.  I  have  used  with 
success  such  agents,  that  is,  they  relieved  temporarily  until  I 
could  adjust  the  displacement.  If  used  to  excess,  they  are  in- 
jurious in  that  the  tampons  dilate  the  vagina,  thus  weakening 
the  supports  of  the  uterus.  If  the  uterus  is  adhered,  engorged 
and  FIRM,  repeated  attempts  at  replacement  are  indicated, 
until  it  is  replaced  or  reduced  in  size.  If  the  uterus  is  very  tender 
care  should  be  exercised  as  to  the  amount  of  force  used.  Some 
advise  the  use  of  a  very  large  sound  but  it  is  extremely  doubtful 
if  any  good  is  accomplished  by  it.  I  rather  think  harm  results. 
The  menstrual  flow  should  be  established  as  soon  as  possible  as 
this  relieves  the  intense  pelvic  engorgement.  This  flow  is  not  a 
regular  menstruation  but  rather  a  metrorrhagia.  The  digital 
local  treatment  is  usually  sufficient  to  start  the  flow.  The  ab- 
dominal treatment  is  similar  to  that  given  in  chronic  metritis 
except  that  more  care  must  be  exercised  on  account  of  the  per- 
itonitis. 


366  DISEASES   OF    WOMEN. 


SUBINVOLUTION. 


SUBINVOLUTION  of  the  uterus  is  an  enlarged  condition, 
which  is  the  result  of  an  imperfect  contraction  or  involution 
after  childbirth  or  abortion.  In  a  typical  case,  the  involution 
should  be  complete  within  six  weeks  after  delivery,  but  in  a  great 
many  cases,  especially  if  there  was  a  laceration  and  the  patient 
not  very  robust,  it  takes  a  much  longer  time.  The  muscular 
elements,  which  were  enormously  increased  in  size  and  number, 
fail  to  undergo  atrophy  and  absorption;  the  blood  vessels  are 
engorged  and  the  lymphatics  distended.  The  connective  tissue 
is  increased  in  amount  and  the  uterine  walls  remain  thick.  The 
enlargement  is,  as  a  rule,  symmetrical,  but  in  some  cases  it  is 
confined  to  one  part,  principally  the  cervix.  This  form,  when 
occurring  in  the  cervix,  may  be  mistaken  for  a  prolapsus.  The 
uterine  cavity,  as  in  the  fibroid  tumor,  is  enlarged. 

CAUSES.  The  causes  of  subinvolution  are  bony  lesions 
affecting  the  innervation  of  the  uterus,  accidents,  or  complica- 
tions of  labor,  and  neglect  during  the  puerperium.  The  bony 
lesions  will  prevent  proper  involution  even  though  great  care  be 
taken  of  the  woman  during  the  lying-in  period.  These  lesions 
are  similar  to  other  bony  lesions  which  affect  uterine  circulation, 
namely,  subluxations  of  the  lumbar  vertebrae,  sacrum,  innomi- 
nates  or  coccyx. 

Recently  a  case  of  subinvolution  came  under  my  observa- 
tion, the  result  of  a  displaced  coccyx  which  occurred  at  child- 
birth. This  kept  up  a  constant  irritation  of  the  perineum  re- 
sulting in  congestion  of  the  pelvic  floor,  vagina  and  uterus,  thus 
hindering  contraction  of  the  uterus. 


SUBINVOLUTION.  367 

Rising  from  the  bed  very  early,  standing  on  the  feet  too  long 
or  over  exertion  too  soon  after  delivery  are  common  causes.  How- 
ever, these  causes  depend  to  a  certain  extent  upon  the  above  men- 
tioned bony  lesions.  If  these  lesions  did  not  exist  the  exciting 
cause  would  not  act  so  readily.  Lacerations  cause  congestion, 
hence  a  disturbance  of  the  normal  involution  of  the  uterus.  A 
resumption  of  the  marital  relations  soon  after  delivery  is  a  com- 
mon cause.  In  such  cases,  the  menses  are  re-established  within 
a  few  months  and  of  course  along  with  this  marked  uterine  en- 
gorgement. The  uterus  is  thus  kept  congested,  there  being  no 
chance  given  it  to  properly  involute.  Frequent  pregnancies  are 
liable  to  be  attended  by  subinvolution  on  account  of  loss  of  tonic- 
ity of  the  muscular  walls  from  frequent  distention.  Another 
very  important,  possibly  the  most  important  cause,  bony  lesions 
excepted,  is  the  non-nursing  of  the  mother  by  the  new  born  baby. 

About  60  per  cent,  of  all  babies  born  of  mothers  who  do  not 
have  to  do  manual  work  for  an  existence,  are  bottle  fed.  Sub- 
involution, not  only  of  the  uterus  and  its  adnexa,  but  of  the 
abdominal  wall,  is  present  in  nearly  every  case.  The  nursing 
of  the  child  has  a  marked  effect  on  uterine  contraction 
which  is  necessary  to  perfect  involution.  This  is  proven 
by  the  fact  that  for  a  week  or  more  after  labor  the  lochial  dis- 
charge is  increased  in  amount  at  each  nursing.  The  after  pains 
are  worst  at  the  time  of  nursing,  and  on  palpation  the  uterus  can 
be  felt  as  a  firmlv  contracted  body.  The  stimulus  to  the  nipple 
resulting  from  the  nursing  reflexly  contracts  the  uterus,  hence 
in  cases  in  which  the  mother  does  not  nurse  the  child  these  stim- 
uli are  absent  and  as  a  consequence  the  uterus  remains  large, 
which  condition  is  called  subinvolution.  The  abdominal  wall 
BECOMES  flabby  and  pendulous;  the  patient  has  a  bad  form. 
All  the  various  kinds  of  abdominal  binders  would  not  prevent 


368  DISEASES    OF    WOMEN. 

this  in  the  above  sort  of  case.  The  pelvic  floor  remains  stretch- 
ed, causing  a  weakening  of  the  uterine  supports.  These  things 
can  in  a  measure  be  prevented.  The  child  should  be  nursed  dur- 
ing the  puerperium  if  it  is  possible  to  do  so,  even  though  there  are 
some  contraindications. 

Childbed  fever,  if  permitted  to  occur,  is  followed  by  a  con- 
gestion and  subinvolution  of  the  uterus.  Retention  of  secundines 
or  a  prolonged  labor  weaken  the  walls  of  the  uterus  and  prevent 
its  proper  contraction  after  childbirth. 

SYMPTOMS.  Nearly  every  symptom,  both  constitu- 
tional and  local,  which  comes  from  a  uterine  affection  attends 
A  SUBINVOLUTION.  Pain,  aches  in  lumbar  and  sacral  regions, 
pelvic  distress  and  bladder  disturbances  are  common;  constipa- 
tion, hemorrhoids,  anorexia  and  nausea  are  found;  chronic  in- 
flammation of  the  uterus  with  its  attending  evils  follow  as  a  re- 
sult of  the  congestion;  abnormal  secretions  and  menstrual  dis- 
orders exist.  The  :most  common  menstrual  disorder  is  Men- 
orrhagia, the  next  dysmenorrhea.  The  health  is  undermined 
and  the  patient  feels  weak  and  of  no  account.  There  is  ina- 
bility to  concentrate  the  mind  and  tendency  to  forget  names. 
Sleep  does  not  refresh  and  the  patient  awakes  with  a  back- 
ache. The  limbs  feel  heavy  and  there  is  difficulty  in  walking. 
Various  reflex  nervous  phenomena  are  present.  These  nervous 
indications  vary  in  degree  from  a  mild  form  of  restlessness  to  the 
hysterical  convulsions.  If  laceration  is  the  primary  cause  these 
nervous  phenomena  are  more  marked.  Anemia  soon  develops 
with  its  weakness  and  sense  of  exhaustion.  If  a  patient  were 
to  come  into  the  office  suffering  with  the  above  symptoms  dating 
from  childbirth,  subinvolution  should  be  suspected  with  lacera- 
tion as  a  cause. 

DIAGNOSIS.     On  digital  examination  the  cervix  is  foiind 


SUBINVOLUTION.  369 

TO  BE  LARGE  AND  SOFT.  The  OS  is  verv  patulous,  sometimes  ad- 
mitting the  examining  finger.  This  patulous  condition  of 
the  external  os  may  come  from  other  causes,  such  as  sexual  ex- 
cesses, and  thus  mislead  the  physician  as  to  the  real  cause.  Dur- 
ing sexual  congress  the  uterus  descends  and  the  os  dilates.  Re- 
peated dilation  soon  results  in  a  permanent  enlargement  to  which 
is  given  the  term  patulous.  The  cervix  is  very  much  thickened 
and  shortened  and  feels  like  a  round  blunt  body.  Tenderness  is 
present,  due  to  the  mflammation  which  usually  accompanies  the 
condition.  When  the  uterus  is  outlined  it  is  found  to  be  consid- 
erably larger  and  softer  than  the  normal. 

On  account  of  the  lack  of  tone,  both  in  the  uterine  walls 
and  ligaments,  retro-displacement  and  prolapsus  are  usually 
present.  The  form  of  retro-deviation  is  commonly  a  retroflexion. 
The  writer  has  seen  many  cases  in  which  the  fundus  was  on  a 
level  with  the  umbilicus.  By  pressure  on  the  posterior  part  of 
the  uterus  through  the  posterior  fornix  or  rectum  the  impulse 
would  be  transmitted  to  the  external  hand  placed  at  the  um- 
bilicus. The  history  of  the  trouble  will  aid  in  the  diagnosis. 
If,  as  mentioned  above,  the  trouble  dates  from  parturition,  the 
patient  getting  up  a  few  days  after  delivery,  and  a  laceration  is 
present,  although  it  can  occur  without  it,  and  the  uterus  is  found 
in  the  above  described  condition,  subinvolution  is  probably  the 
condition. 

The  patient  should  be  kept  in  bed  at  least  nine  days  after 
delivery,  regardless  of  her  apparent  strength,  for  the  uterus  is 
usually  too  heavy  before  the  end  of  a  week  to  be  held  in  position 
by  the  weakened  ligaments  while  she  is  in  the  erect  posture. 
There  can  be  given  no  hard  and  fast  rule  regarding  the  number  of 
days  that  the  patient  should  be  kept  in  bed,  for  one  patient  may 
get  up  before  the  end  of  a  week  and  no  apparent  evil  effects  fol- 


370  DISEASES    OF    WOMEN. 

low;  another  may  do  likewise  and  become  a  chronic  invalid,  so, 
to  be  on  the  safe  side,  keep  her  in  bed  at  least  nine  days,  or  as 
much  longer  as  is  necessary  for  her  to  recuperate. 

TREATMENT.  The  treatment  is  similar  to  that  outlined 
for  chronic  inflammatory  conditions  of  the  uterus.  Bony  dis- 
placements should  be  corrected  and  the  patient  should  rest  as 
much  as  possible.  Treatment  should  also  be  given  over  the  course 
of  the  veins  returning  the  blood  to  the  heart.  The  pelvic  floor 
may  be  strengthened  by  a  strong  stimulating  treatment  in  the 
lumbar  and  sacral  regions  to  free  and  stimulate  the  nerve  force 
to  the  muscles  comprising  the  floor.  Separating  the  knees  against 
resistance  strengthens  the  muscles.  A  muscle  fiber  relaxes 
when  the  amount  of  nerve  force  to  it  is  lessened.  In 
subinvolution,  the  lesions  mentioned  interfere  with  or  shut  off 
these  nervous  impulses,  the  muscle  fibers  remaining  relaxed  and 
large.  Correction  of  these  lesions  is  necessary  in  order  to  get 
proper  contraction  of  the  muscle  fibers  of  the  uterus.  The  stim- 
ulating treatment  referred  to  above,  helps  temporarily. 

To  temporarily  relieve  the  congestion,  place  the  patient  in 
the  knee-chest  position  while  giving  the  abdominal  treatment, 
which  consists  principally  of  lifting  the  viscera  out  of  the  true 
pelvic  cavity.  It  is  advisable  to  instruct  her  to  assume  this  posi- 
tion for  several  minutes  each  night  just  before  retiring.  This 
lessens  the  congestion  and  diminishes  the  weight  of  the  uterus. 
The  uterus,  if  found  displaced,  should  be  put  in  its  proper  posi- 
tion. If  it  does  not  stay  in  place,  and  it  probably  will  not,  it 
should  be  replaced  every  week  or  so,  this  depending  however,  on 
the  character  of  the  symptoms.  By  replacing  the  uterus  the 
passive  congestion  is  greatly  relieved.  If  laceration  is  the  cause 
of  the  congestion  and  subinvolution,  treatment  should  be  directed 
to  it,  since  the  subinvoluted  condition  will  exist  as  long  as  the 
irritation  remains. 


SUPERINVOLUTION.  371 


SUPERINVOLUTION. 


SUPERIXVOLUTION  is  a  condition  just  the  opposite  to  that 
of  subinvolution  of  the  uterus.  As  the  word  impUes,  it  is  too 
rapid  or  excessive  involution.  It  is  usually  found  following  par- 
turition, but  some  cases  are  due  to  senile  atrophy.  It  is  a  rare 
condition  and  is  probably  connected  with  abortion  more  fre- 
quently than  with  parturition.  The  uterus  shrinks  or  contracts 
beyond  the  physiological  limit,  becoming  very  small,  degenera- 
tion setting  in,  all  of  which  conditions  combine  to  make  it  soft  and 
excessively  mobile.  The  non-puerperal  atrophy  is  sometimes 
caused  by  pressure  from  a  fibroid  tumor  or  it  may  be  the  result 
of  an  operation.  Menstruation  is  affected,  there  being  amen- 
orrhea or  a  scanty  flow.  Sterility  is  a  sequel  if  it  occurs  be- 
fore the  climacteric.  Some  patients  complain  of  various  reflex 
disturbances,  but  these  are  rare  as  compared  with  other  uterine 
affections,  since  there  is  little  or  no  inflammation  in  the  uterus. 
Treatment  should  be  directed  to  a  buUding  up  of  the  general  sys- 
tem and  increasing  the  nutrition  of  the  uterus.  In  the  senile 
atrophy  which  occurs  after  the  change  of  life,  few  symptoms  are 
present,  it  being  a  physiological  process.  In  these  cases  treat- 
ment does  little  or  no  good  and  is  seldom  indicated. 


372  DISEASES   OF   WOMEN. 


PERIMETRITIS. 


PERIMETRITIS  is  an  inflammation  of  the  pelvic  peri- 
toneum, called  also  local  pelvic  peritonitis.  It  is  a  very 
frequent  disease  and  one  which  results  in  the  formation  of  ad- 
hesions which  fix  the  uterus  to  some  neighboring  structure.  It 
is  usually  a  localized  affection,  being  confined  to  that  part  of  the 
peritoneum  covering  the  uterus.  The  parietal  layer  of  peri- 
toneum lining  the  abdominal  wall  is  continued  as  a  layer  over  the 
pelvic  structures,  the  dipping  of  this  layer  between  the  pelvic 
viscera  constituting  the  ligaments  of  the  viscera.  The  func- 
tion of  the  pelvic  peritoneum  is  to  permit  free  motion  and  to  sup- 
port, hence  two  forms  of  disorders  result  from  a  perversion  of  its 
function,  viz.,  too  free  mobility  and  lessened  mobility.  The 
first  permits  of  displacements,  especially  prolapsus.  The  second 
is  the  more  pathological  of  the  two  because  of  the  inflammation 
which  is,  or  was,  present.  The  uterus  is  like  a  joint — it  has  liga- 
ments and  mobility.  If  mobility  can  be  restored  to  the  uterus 
(or  joint), its  function  will  be  normal  and  congestion  and  inflam- 
mation disappear.     An  inflamed  uterus  is  seldom  if  ever  mobile. 

When  inflammation  of  the  peritonevim  sets  in,  nature  pre- 
vents the  diffuse  form  of  peritonitis  by  forming  an  exudate, 
thus  producing  adhesions  which  localize  the  inflammation. 
It,  like  inflammation  of  other  serous  surfaces,  is  first  preceded  by 
congestion  followed  by  effusion,  that  is,  the  throwing  out  of  the 
exudate.  This  exudate  becomes  organized  and  forms  scar  or 
fibrous  tissue.  It  is  very  similar  to  pleuritis  as  to  cause,  path- 
ology and  termination,  that  is  there  is  an  inflammation  of  adja- 
cent organs,   secretory   changes  and   the   formation   of  adhesive 


PERIMETRITIS.  373 

bands.     It  is  regarded  as  a  very  important  disease,  for  certainly 
in  point  of  frequency  it  is  second  only  to  endometritis. 

CAUSES.  The  causes  of  perimetritis  depend  upon  a  disturb- 
ed uterine  circulation.  This  disturbance  is  usually  the  result  of 
uterine  inflammation.  The  inflammation  spreads  by  continuity 
of  tissue,  to  the  peritoneum  covering  the  uterus.  In  acute  in- 
flammation of  the  uterus  all  the  pelvic  contents  are  more  or 
less  inflamed.  If  a  displacement  exists  the  inflammation  more 
rapidly  spreads  to  the  peritoneum,  and  in  almost  ever}^  case  ad- 
hesions form. 

Specific  infection  reaches  the  peritoneal  cavity  by  way  of  the 
Fallopian  tubes  and  sets  up  a  chronic  form  of  inflammation  which 
is  very  intractable.  Fluids  also  escape  into  the  peritoneal  cav- 
ity in  the  same  way.  Injections,  and  especially  medicated  so- 
lutions forced  into  the  uterus,  have  resulted  in  a  part  of  the  fluid 
escaping  into  the  peritoneal  cavity  and  setting  up  an  inflamma- 
tion. 

Endometritis  also  produces  this  local  form  of  peritonitis 
by  the  inflammation  spreading  to  the  peritoneum  through  the 
Fallopian  tubes.  Any  cause  that  produces  endometritis,  espec- 
ially the  acute  form,  will  cause  perimetritis.  Acute  metritis 
invariably  results  in  peritoneal  adhesions.  In  such  cases  there 
is  present  everything  necessary,  such  as  an  exudate,  proximity 
from  enlargement,  fixation  and  inflammation. 

The  ACUTE  cases  depend,  in  most  instances,  on  a  sudden 
DISPLACEMENT  of  the  utcrus,  which  sets  up  an  acute  congestion 
and  inflammation  of  the  uterus  and  neighboring  structures. 
Sometimes  general  peritonitis  results  or  inflammation  of  the 
bowels  follows.  Exposure  during  the  menstrual  flow  causes  a 
congested  condition  of  the  ovaries  and  other  pelvic  organs.  If  a 
general  inflammation  is  produced  it  becomes  localized  as  it  re- 


374  DISEASES    OF    WOMEN. 

cedes  and  adhesions  form.  Inflammation  of  the  bowels  fre- 
quently spreads  to  the  pelvic  organs  and  there  sets  up  secondary 
inflammatory  changes. 

SYMPTOMS.  In  acute  cases  the  symptoms  are  those  of  an 
acute  metritis,  viz.,  great  tenderness  of  the  abdominal  walls, 
swelling  of  the  abdomen,  contraction  of  the  abdominal  muscles, 
chills,  fever  and  localized  pain.  The  pain  may  be  colicky  and 
referred  to  the  intestines.  The  limbs  are  drawn  up  to  relieve 
the  traction  on  the  abdominal  muscles.  The  symptoms  may 
simulate  appendicitis  and  on  this  account  care  should  be  taken 
in  the  diagnosis.  The  vaginal  walls  are  hot  and  the  uterus  fixed 
by  the  contracted  ligaments.  If  this  condition  is  allowed  to  con- 
tinue, death  will  ensue  from  diffuse  peritonitis.  After  the  acute 
symptoms  have  abated,  the  exudate  becomes  hardened  and 
undergoes  structural  changes,  soon  forming  scar  or  fibrous  tissue. 
These  adhesions  between  the  layers  of  the  peritoneum  prevent 
motion  of  the  uterus  and  at  first  it  is  fixed  in  one  position,  which 
gives  it  a  board  like  feeling.  They  soon  begin  to  be  absorbed, 
but  a  few  remain  on  the  side  in  which  there  was  the  greatest  in- 
flammation and  tend  to  draw  the  uterus  and  fix  it  toward  that 
side.  The  patient  complains  of  a  drawing  or  pulling  sensa- 
tion in  the  affected  side.  The  uterus  gradually  regains  more 
freedom  of  motion  the  longer  the  adhesions  exist,  unless  new  ones 
form,  since  they  are  stretched  with  each  jar  and  movement  of 
the  body.  In  some  cases  the  uterus,  when  retroverted,  is  bound 
down  to  the  rectum  and  adjacent  structures  by  these  adhesions. 

By  examination  through  the  fornices  they  can  sometimes  be 
felt.  On  rectal  examination  the  posterior  adhesions  can  be  out- 
lined if  they  are  much  thickened.  If  examination  is  made  with 
the  patient  in  the  genu-pectoral  position,  the  adhesions  will  feel 
as  cords,  made  tense  by  the  uterus  falling  away  from  the  rectum. 


SUBINVOLUTION.  375 

In  the  dorsal  position  the  uterus  if  normal  should  be  freely  mov- 
able in  all  directions.  By  testing  this  mobility  and  noticing  the 
side  in  which  there  is  restriction  of  motion  the  location  of  the  adhes- 
ions can  thus  be  ascertained.  Sometimes  in  bad  cases  the  uterus 
IS  IMMOVABLE,  it  being  held  as  in  a  vice. 

The  reflex  symptoms  are  those  found  in  inflammatory  con- 
ditions of  the  uterus,  such  as  sideaches.  backache,  headache  and 
nervous  phenomena.  Sterility  is  the  result  and  menstrual. 
DISORDERS,  especially  dysmenorrhea,  are  frequent. 

PROGNOSIS.  In  the  acute  form  the  dancjer  lies  in  it  be- 
coming a  DIFFUSE  PERITONITIS.  If  the  inflammation  can  be 
checked,  it  will  become  localized  by  the  exudation  and  adhes- 
ions which  are  formed.  These  adhesions  which  hold  the  uterus 
in  one  position  should  be  absorbed  or  broken  up  if  the  inflammation 
has  entirely  receded.  Absorption  is  a  slower  but  safer  process,  and 
when  it  can  be  accomplished  good  results  follow.  As  long  as  the 
lesions  exist,  the  patient  will  be  troubled  with  various  reflex  pains 
which  accompany  displacement  and  inflammation  of  the  uterus. 

TREATMENT.  The  treatment,  in  the  acute  stage,  is  to  cor- 
rect the  displaced  uterus  if  it  exists. then  relaxing  the  contractured 
muscles  found  along  the  lower  part  of  the  spine.  Work  around 
the  inflamed  parts  lessens  the  congestion  and  tenderness.  The 
treatment  then  can  be  gently  given  over  the  point  of  inflammation. 
By  gradually  and  steadily  increasing  the  pressure,  the  inflamed 
organs  can  be  manipulated,  and  when  this  can  be  done,  the  in- 
flammation can  be  worked  out. 

In  the  chronic  form,  treatment  applied  to  the  lower  lumbar 
region  is  beneficial  since  it  promotes  a  better  pelvic  circulation. 
Any  treatment  that  increases  the  arterial  circulation  increases 
the  absorptive  qualities  and  this  is  necessary  if  the  adhesions  are 
to  be  absorbed.     This  is  the  proper  way  to  treat  adhesions,  that 


376  DISEASES    OF    WOMEN. 

is,  BY  INDUCING  ABSORPTION.  Another  method  is  to  break  up 
the  adhesions  by  gradually  stretching  them  or  b}^  using 
FORCE.  There  is  danger  in  breaking  them  up  suddenly,  since 
hemorrhage  and  inflammation  may  result.  This  hemorrhage  is 
in  the  peritoneal  cavity  and  may  excite  a  diffuse  peritonitis.  By 
gently  stretching  the  adhesions  every  few  days  and  by  increasing 
the  pelvic  circulation,  which  things  are  accompanied  by  repeated 
attempts  at  replacement,  the  fibrous  tissues,  which  are  the  re- 
sult of  the  inflammatory  exudates,  will  gradually  disappear. 
The  adhesions  are  stretched  easily  by  movements  of  the  uterus 
as  obtained  by  local  treatment,  or  deep  massage  over  the  uterus 
through  the  abdominal  wall.  In  case  of  adhesions  fixing  the 
uterus  in  retroversion,  the  uterus  can  be  moved  forward  by  rec- 
tal treatment.  By  gently  pushing  the  uterus  forward  these  ad- 
hesions will  be  thinned  by  constant  stretching,  and  finally  dis- 
appear. 

Abdominal  treatment  given  directly  over  the  uterus,  stim- 
ulates uterine  contraction  and  betters  the  pelvic  circulation. 
The  uterus  can  be  moved  in  this  way,  a  thing  to  be  desired  in  the 
treatment  of  adhesions.  Circular  massage  over  the  uterus  is 
one  of  the  best  ways  to  induce  uterine  contraction.  I  rely  upon 
it  in  most  cases  of  post  partum  hemorrhage. 

Since  metritis  complicates  most  cases  of  endometritis,  the 
uterus  is  found  congested  and  enlarged.  From  this  it  can  be 
seen  that  any  treatment  that  excites  uterine  contraction  increases 
uterine  circulation,  hence  absorption.  In  these  cases  as  in  others, 
the  real  trouble  and  cause  must  be  corrected.  The  frequency 
of  treatment  depends  upon  what  is  done  at  a  treatment.  If  ad- 
hesions are  broken  up,  wait  a  few  days  before  giving  another 
treatment  or  you  may  set  up  a  fresh  inflammation.  If  only  the 
congestion  is  reduced,  frequent  treatment  should  be  given.     If  a 


PERIMETRITIS.  377 

bone  is  set  at  the  first  treatment,  lea v^e  it  alone.  If  the  bony  lesion 
is  not  corrected,  treat  it  again  soon,  unless  inflammation  exists. 

Adhesions  are  frequently  met  with  and  are  very  hard  condi- 
tions to  cure.  By  constantly  stretching  them  they  can  be  grad- 
ually broken  up  and  absorbed,  but  care  should  be  exercised  lest 
THE  INFLAMMATION  BE  MADE  WORSE,  hemorrhage  produced; 
followed  by  a  fresh  attack  of  peritonitis.  The  ciuestion  is  often 
asked,  when  should  an  adhesion  be  broken  up?  In  cases  of  dis- 
placements PRODUCING  mechanical  OR  REFLEX  SYMPTOMS, 
in  which  the  uterus  is  held  down  by  adhesions,  even  though  there 
is  little  or  no  inflammation,  they  should  he  broken  up.  If  the 
uterus  is  displaced  and  there  is  very  much  inflammation  the  ex- 
isting adhesions  should  be  absorbed.  If  the  uterus  is  in  its 
normal  position  it  is  not  likely  that  adhesions  exist,  but  if  they 
do  they  may  cause  trouble  and  should  be  broken  up.  As  a  rule 
all  cases  of  displacement  which  are  complicated  b}"  these  adhe- 
sions should  be  treated. 

In  many  cases,  especially  in  the  early  stages,  there  is  an  ex- 
udation of  an  agglutinating  nature  which  sticks  or  glues  the  per- 
itoneal surfaces  together.  In  such  cases  simply  place  the  patient 
in  the  knee-chest  position  and  direct  a  few  light  blows  on  the 
lumbo-sacral  region,  thus  causing  the  peritoneal  surfaces  to  sep- 
arate and  the  uterus  to  be  replaced. 

ADHESIONS  uniting  the  cervix  to  the  vaginal  walls  are  fre- 
quently found.  I  had  a  case  recently  in  which  the  cervix  could 
not  be  outlined,  the  fornices  being  completely  filled  with  inflam- 
matory exudates.  The  uterus  was  immavable  and  ver}^  much 
inflamed.  These  conditions  usually  result  from  a  long  standing 
vaginitis.  In  the  above  case  the  woman  had  had  uterine  dis- 
ease for  years. 

The  diagnosis  can  be  made  by  digital  examination  or  by 


378  DISEASES    OF    WOMEN. 

the  use  of  the  speculum.  On  vaginal  examination  only  a  slight 
elevation  or  protrusion  in  the  upper  part  of  the  vagina  can  be 
felt.  The  parts  are  tender,  the  degree  of  soreness  depending  upon 
the  amount  of  inflammation.  The  cervix  can  not  be  encircled 
with  the  examining  finger  and  the  os  is  found  as  a  depression 
at  the  uterine  end  of  the  vagina.  The  usual  symptoms  of  me- 
tritis are  present. 

These  kinds  of  adhesions  are  treated  in  a  way  similar  to  per- 
itoneal adhesions,  that  is,  by  increasing  the  blood  supply  and 
gradually  breaking  them  up.  By  attempting  to  encircle  the 
cervix  with  the  internal  finger  the  adhesions  can  be  readily  reach- 
ed and  stretched  or  broken  up  unless  the  case  is  very  chronic. 
In  these  chronic  cases  the  adhesions  are  so  fibrous  that  it  is  hard 
to  get  absorption  or  even  break  them  up.  In  such  cases  the 
treatment  should  be  directed  to  relieve  the  inflammation  if  any 
exists.  If  these  vaginal  adhesions  are  causing  very  little  or  no 
trouble,  treatment  is  not  indicated.  If  they  fix  the  uterus 
in  an  abnormal  position  or  there  is  a  co-existing  inflammation  of 
the  uterus,  they  should  be  removed  if  possible. 


PHYSIOLOGICAL    PERIODS.  379 


PHYSIOLOGICAL  PERIODS. 


THE  LIFE  of  a  woman  is  divided  into  certain  physiological 
periods.  The  period  to  puberty,  varying  from  ten  to  fifteen  years, 
is  called  infancy  or  childhood.  The  commencement  of  the  per- 
iod of  sexual  activity,  usually  about  thirty  years  in  length,  is 
called  maturity.  The  menopause  or  climacteric  indicates  the 
cessation  of  sexual  activity  and  menstruation.  The  period  fol- 
lowing the  change  of  life  is  called  senility.  The  two  most  im- 
portant are  the  transitional  periods,  puberty  and  the  meno- 
pause, for  at  these  times  great  nervous  changes  take  place,  ac- 
companied by  various  reflex  phenomena  and  anatomical  changes. 
On  account  of  these  nervous  changes  disease  at  these  times  is 
liable  to  get  a  foothold  and  is  very  hard  to  relieve. 

INFANCY.  During  the  period  of  life  up  to  puberty  the 
sexual  organs  are  physiologically  dormant.  The  uterus  is 
small  and  non-developed  and  the  ovaries  in  a  condition  of  inac- 
tivity. The  mammary  glands  have  not  begun  to  enlarge;  hair 
has  not  begun  to  appear  on  the  mons  Veneris,  and  the  greater 
lips  are  not  fuUy  developed,  so  that  the  lesser  lips  protrude  be- 
yond the  vulva.  During  this  period  the  evil  practices  such  as 
masturbation  are  frequentl}^  contracted.  If  it  is  near  puberty, 
it  brings  on  premature  activity  of  the  sexual  apparatus.  The 
clitoris  becomes  congested  and  in  some  cases  inflamed.  Ad- 
hesions frequently  form  which  result  in  some  cases  in  a  hooded 
clitoris.  This  causes  a  loss  of  nerve  force  and  is  associated  with 
various  nervous  diseases,  such  as  spasms  and  chorea. 

PUBERTY.  Puberty  is  that  period  at  which  the  genital 
organs    are   capable  of  exercising  their  physiological    function. 


380  DISEASES    OF    WOMEN. 

This  varies  in  different  races  and  countries.  In  cold  countries 
puberty  develops  late,  that  is,  on  an  average  of  about  the  age  of 
thirteen  or  fourteen.  In  temperate  climates  it  occurs  at  about  a 
somewhat  earlier  age.  In  warm  climates  it  comes  quite  early. 
Girls  reared  in  the  country  as  a  rule  develop  late.  On  the  con- 
trary, girls  in  the  cities  develop  early  on  account  of  the  associa- 
tion, kind  of  food  and  general  excitement  of  city  life.  At  pu- 
berty the  UTERUS  and  appendages  undergo  great  struc- 
tural CHANGES.  The  organs  that  were  hitherto  dormant  and 
undeveloped,  become  active  and  increase  in  size;  the  nervous 
system  becomes  dominant  and  is  susceptible  to  external  influ- 
ences. 

The  progress  of  development  of  the  two  sexes  up  to  the  tenth 
or  eleventh  year  is  equal.  The  boy  develops  imperceptibly  from 
youth  to  manhood  without  any  special  disturbances.  The  fe- 
male, on  the  contrary  changes  rapidly  to  womanhood  and  her 
nervous  system  is  taxed  to  maintain  the  equilibrium  and  proper 
development  of  the  sexual  organs  at  the  same  time.  The  nerve 
force  that  ought  to  be  used  for  their  development  should  not  be 
directed  into  other  channels  or  else  the  pelvic  organs  suffer.  It 
is  a  critical  time  and  upon  its  normal  termination  depends 
MUCH  of  the  after  health  and  freedom  from  uterine  disease. 
A  great  many  women  date  their  trouble  back  to  puberty.  They 
have  never  menstruated  properly  and  if,  in  such  cases,  the  his- 
tory can  be  obtained,  there  will  be  found  something  that  pre- 
vented the  normal  approach  of  puberty,  such  as  overwork,  both 
mental  and  physical,  exposure  or  accident. 

Puberty  is  marked  by  a  change  in  the  pelvis.  The  hips 
broaden  and  the  form  becomes  rounded  from  the  accumula- 
tion of  fat;  hair  appears  on  the  pubis  and  labia  majora,  and  the 
mammary  glands  begin  to  enlarge;  the  ovaries  become  increased 


PHYSIOLOGICAL    PERIODS.  381 

in  size  and  both  the  blood  and  nerve  supply  to  them  is  increased 
in  amount;  ovulation  begins,  and  with  it  the  appearance  of  men- 
struation. These  things  are  indicative  of  the  sexual  nervous 
system  approaching  that  maturity  which  makes  a  woman  capa- 
ble of  procreating.  During  the  change  of  puberty  the  patient 
sometimes  becomes  anemic,  the  appetite  abnormal  in  that  there 
is  a  craving  for  peculiar  kinds  of  food,  eruptions  appear  on  the 
face,  and  she  complains  of  weakness  and  lassitude.  The  symp- 
toms should  disappear  if  the  change  to  maturity  is  normally  made, 
but  this  is  not  the  case  in  many  patients,  who  remain  weak  and 
nervous  on  account  of  the  unequal  nervous  distribution.  As  a 
result  of  this,  bony  lesions  are  readily  produced  at  this  time, 
because  the  muscles  and  ligaments  are  flabby  and  relaxed. 

MATURITY  comprises  that  period  between  puberty  and  the 
menopause  or  the  fruitful  period  of  a  woman's  life.  It  should  be 
the  period  of  least  disease  and  disturbance,  since  it  is  one  of  great 
physiological  activity,  yet  menstrual  disorders  and  inflammatory 
conditions  are  frequently  found. 

If  the  function  of  childbearing  is  not  interfered  with  by 
artificial  means,  the  woman  will  have  perfect  health  unless  acci- 
dents, strains  or  injuries  occur.  A  woman  is  predisposed  to  dis- 
ease after  she  reaches  the  age  of  thirty  if  she  has  not  borne  children. 
Childbirth  changes  her  nervous  system,  alters  her  in  various 
ways  and  fulfils  the  function  for  which  she  was  designed.  A 
great  many  diseases  are  contracted,  and  they  are  on  the  increase, 
as  a  result  of  interference  with  this  function.  The  accidents  of 
childbirth,  such  as  laceration,  which  occur  during  this  period, 
may  be  the  foundation  of  future  disease.  The  period  of  matur- 
ity is  comparatively  free  from  neuroses  and  the  various  mental 
and  imaginary  diseases.  It  is  rare  to  get  a  case  of  hysteria  in  a 
woman  who  has  borne  children  unless  there  has  been  a  laceration 


382  DISEASES    OF   WOMEN. 

which  has  not  healed.  The  suffering  and  changes  prochiced  make 
her  able  to  control  herself.  Fibroid  tumors  are  the  most  com- 
mon of  the  growths  which  occur  during  this  period. 

THE  MENOPAUSE  is  the  period  at  which  menstruation 
ceases.  The  average  age  at  which  the  change  of  life  occurs  is 
FORTY-FIVE.  It  is  also  called  the  climacteric,  which  is  taken 
from  a  word  meaning  the  top  round  of  the  ladder.  It  is  a  physiol- 
ogical process  and  marks  the  close  of  the  sexual  activity  of  the 
woman.  The  popular  opinion  is  that  the  later  the  menses  com- 
mence the  later  the  menopause  occurs,  but  in  fact  just  the  op- 
posite exists.  If,  in  a  woman  who  is  fully  developed,  the  menses 
come  on  late,  the  period  of  sexual  activity  will  be  short,  that  is 
the  menopause  will  appear  at  about  the  age  of  forty.  The  ex- 
planation offered  is,  that  the  stronger  the  sexual  organs  the  longer 
they  will  retain  their  power  of  reproduction,  hence  menstruation 
will  continue  longer.  The  weaker  the  generative  organs,  the 
later  the  puberty,  the  shorter  the  period  of  maturity  and  the 
fewer  pregnancies. 

The  liENGTH  of  the  menopause  varies.  Usually  it  covers  a 
period  of  from  one  to  two  years;  in  extreme  cases  it  lingers 
through  a  period  of  several  years.  The  writer  has  treated  many 
cases  in  which  the  change  of  life  lasted  from  five  to  ten  years. 
Cold  climates  delay  puberty  and  produce  an  early  menopause; 
warm  climates  have  the  reverse  effect.  The  average  number 
of  children  per  family  is  less  in  cold  than  in  warm  climates. 

The  cause  of  the  menopause  is  in  most  cases  a  physiological 
one,  but  it  may  be  artificially  produced.  At  this  time  the 
ruling  organs,  the  ovaries,  cease  their  activity,  hence  the  stim- 
ulus which  the  uterus  receives  from  the  ovaries  is  absent.  Im- 
pregnation is  no  longer  possible,  therefore  menstruation  is  un- 
necessary.    The  removal  of  the  ovaries  by  operation,  or  a  struc- 


PHYSIOLOGICAL    PERIODS.  383 

tural  disease  of  them,  brings  on  a  premature  menopause.  The 
operation  called  ovariotomy  is  often  resorted  to  in  uterine  dis- 
ease. Wasting  diseases,  shock,  either  physical  or  mental,  which 
unfit  the  woman  for  childbearing,  often  bring  on  a  premature 
menopause,  especially  if  she  is  already  approaching  it  at  the  time 
of  accident.  Chronic  metritis  predisposes  to  an  early  menopause, 
and  one  attended  with  various  functional  disturbances. 

The  ANATOMICAL  CHANGES  are  based  on  the  cessation  of 
ovarian  influences;  the  uterus  undergoes  atrophy,  becoming  small 
and  hard.  In  premature  menopause,  and  particularly  that  form 
due  to  ovariotomy,  the  uterus  is  said  to  at  first  become  a  little 
larger  and  heavier.  Hyperemia  exists,  on  which  account  the 
menstrual  disorders  occur.  The  vagina  also  becomes  injected 
and  swollen  with  increased  secretion.  The  conditions  last  sev- 
eral months,  followed  by  atrophy.  The  vagina  atrophies, 
becoming  pale  and  losing  its  rugae;  it  shortens  and  becomes 
narrower.  The  uterus  gradually  becomes  smaller,  especially 
its  vaginal  portion.  The  changes  occur  earlier  in  premature  or 
artificial  menopause  than  in  the  normal,  the  atrophic  changes 
being  completed  within  a  few  months,  particularly  if  the  ovaries 
have  been  removed.  Obesity  results  in  about  80  per  cent,  of 
all  cases.  Nervous  phenomena  are  common,  ranging  from 
hysteria  to  insanity.  The  sexual  function  is  impaired  and 
in  a  short  time  sexual  feeling  is  lost.  The  vaginal  canal  becomes 
so  small  in  some  cases  that  coition  is  no  longer  possible.  In 
others  it  closes  entirely,  giving  rise  to  retention  of  the  uterine 
secretions. 

The  mucous  membrane  undergoes  changes  in  which  the 
glandular  elements  are  lost.  In  cases  of  metritis  these  atrophic 
changes  are  lessened  or  even  entirely  absent,  the  uterus  remain- 
ing large  and  congested,  giving  rise  to  leucorrhea,  often  irritating, 


384  DISEASES    OF    WOMEN. 

displacement  and  irregular  hemorrhages.  In  the  natural  meno- 
pause the  vagina,  having  undergone  senile  atrophy,  becomes 
smaller  and  weaker.  The  walls  are  not  held  permanently  to- 
gether and  as  a  result  prolapsus  or,  in  some  cases,  procidentia 
occurs.  The  walls  lose  their  rugae  and  a  great  part  of  their  elas- 
ticity. This  is  more  marked  in  some  cases  which  are  preceded 
by  chronic  uterine  trouble  covering  a  period  of  years.  The  for- 
nices  become  shallow,  and  in  some  cases,  entirely  obliterated. 
The  cervix  can  with  difficulty  be  outlined  in  such  cases,  it  being 
felt  as  a  hardened  body  with  a  depression  in  its  center  corres- 
ponding to  the  OS  uteri.  The  ovaries  atrophy  and  the  Graafian 
follicles  disappear.  They  become  flattened  and  hardened  and 
are  covered  with  scars,  the  remains  of  the  rupture  of  the  Graaf- 
ian follicles.  Dense  fibrous  tissue  replaces  the  atrophied  and 
degenerated  parts  of  the  ovaries.  The  Fallopian  tubes  shrink 
and  become  shorter,  lose  their  ciliated  epithelium,  and  some- 
times the  walls  unite,  thus  obliterating  the  lumen  of  the  tubes. 
The  vulva  undergoes  degenerative  changes;  the  ostium  vaginae 
becomes  patulous,  thus  exposing  the  vestibule.  The  breasts 
degenerate,  usually  becoming  smaller  and  flatter;  the  glandular 
elements  disappear  and  are  replaced  by  fat  in  cases  in  which  the 
size  is  retained.  The  patient  usually  becomes  obese  but  in  some 
cases  there  is  loss  of  flesh.  The  tendency  to  the  development  of 
malignant  growths  increases  at  this  time. 

Premature  menopause  is  followed  by  obesity  unless  it  is  com- 
plicated by  other  diseases.  Amenorrhea  is  frequently  found  in 
obese  women,  the  result  of  inactivity  of  the  ovary,  which  is  also 
the  probable  cause  of  the  obesity.  It  is  a  well  know  n  fact  that 
the  more  obese  the  patient,  whether  male  or  female,  the  smaller 
the  genitalia,  particularly  the  ovaries  or  testes.  Weakness  of 
these  organs  follows  and  in  very  obese  women  the  function  is 


PHYSIOLOGICAL    PERIODS.  385 

SUSPENDED,  that  is,  there  is  amenorrhea,  sterility  and  atrophy- 
similar  to  that  of  the  climacteric.  The  physiological  changes 
are  those  of  cessation  of  function  of  the  internal  organs  of  genera- 
tion, namely,  cessation  of  menstruation  and  ovulation. 

SYMPTOMS.  The  symptoms  of  the  menopause  may  be 
divided  into  two  classes:  First,  the  local  symptoms  which  are 
due  to  the  menstrual  changes;  and  second,  the  reflex  or  systemic 
disturbances  which  are  so  common.  The  first  symptom  of  the 
approach  of  the  menopause  is  the  Irregular  menstruation.  The 
menstruation  may  be  delayed,  it  occurring  at  the  fifth  or  sixth 
week,  or  it  may  come  on  at  any  time.  These  menstrual  changes 
in  a  woman  past  forty  constitute  the  cardinal  indications  of 
the  approach  of  the  menopause.  The  amount  varies,  sometimes 
being  increased,  sometimes  lessened,  but  there  is  usually  hem- 
orrhage. Sometimes  the  hemorrhage  is  so  profuse  that  it  threat- 
ens the  patient's  life;  in  such  cases  cancer  should  be  suspected. 

The  flow  is  prolonged,  sometimes  lasting  from  six  to  eight 
days,  and  in  some  cases  is  continuous  for  several  weeks.  This 
is  an  abnormal  symptom  and  an  examination  should  be  made 
lest  there  be  a  malignant  disease.  Irregular  hemorrhages,  called 
metrorrhagia,  may  occur  irregularly  for  years,  sometimes  the 
patient  skipping  several  months;  it  recurring  after  exertion. 
Reed  says  that  at  the  menopause  lurking  cancer  advances  by 
leaps,  and  that  any  metrorrhagia  at  this  time  of  life  should  ex- 
cite suspicions  of  cancer.  An  osteopathic  treatment,  which 
increases  the  blood  supply  to  the  pelvic  organs,  will  frequently 
bring  on  the  flow  even  after  it  has  ceased  for  a  year.  It  is  not  an 
alarming  symptom,  and  frequently  proves  beneficial.  This  is 
especially  true  in  an  abrupt  cessation  of  the  menses.  If  they  do 
not  stop  in  the  proper  way,  the  patient  will  have  trouble  until 
menstruation  appears  again. 


386  DISEASES    OF   WOMEN. 

The  reflex  symptoms  are  many  and  cover  the  entire  cate- 
gory of  reflected  troubles.  The  circulatory  changes  are  first 
noticed.  The  head  is  congested,  causing  a  flushed  face,  insomnia, 
or  a  restless  sleep  disturbed  by  dreams.  Vertigo  is  common, 
also  a  roaring  and  buzzing  in  the  ears,  or  tinnitus  aurium.  A 
part  of  the  body  may  become  numb,  the  arm  being  the  part  most 
frequently  affected  in  this  way.  Eye  sight  is  affected,  it  being 
blurred,  or  spots  appear  in  the  field  of  vision.  The  character- 
istic vaso-motor  changes  inducing  hot  and  cold  flashes  or  a  local- 
ized congestion  are  commonly  present.  The  patient  suddenly 
breaks  out  into  a  cold  perspiration  usually  localized  along  the 
spinal  column  or  the  course  of  a  rib.  In  some  cases  the  head 
becomes  very  hot,  or  a  general  increase  of  temperature  may 
occur.  The  heart  is  commonly  attacked,  causing  palpitation, 
tachycardia  and  dyspnea.  It  becomes  very  weak  with  the  pulse 
very  indistinct,  or  it  may  become  labored  in  its  action.  Syncope 
follows  if  the  heart  is  much  weakened,  but  it  is  seldom  fatal. 
This  follows  any  mental  shock  such  as  a  sudden  fright.  In  such 
cases  the  patient  should  be  placed  in  the  dorsal  position,  with 
her  head  low,  then  the  ribs  over  the  heart  should  be  raised, 
giving  the  heart  more  room  in  which  to  work.  An  intense  pru- 
ritus vulvae  is  sometimes  found,  accompanied  by  a  leucorrheal 
discharge.  This  is  the  result  of  a  disturbance  of  the  circulation 
of  the  vagina  and  vulva.  The  various  mucous  membranes  of  the 
body  become  congested,  resulting  in  a  catarrhal  condition.  Hem- 
optysis occurs  in  some  cases,  hematemesis  in  others.  The 
hemorrhoidal  plexus  of  veins  in  case  of  piles,  bleeds  very  freely 
at  this  time.  These  various  sensory  and  circulatory  disturbances 
are  supposed  to  be  due  to  a  retention  of  blood  which  does  not 
find  an  outlet  at  the  menstrual  period. 

The  nerve  force  is  deranged  on  account  of  the  changed  con- 


PHYSIOLOGICAL    PERIODS.  387 

dition  of  the  pelvic  circulation.  Like  the  onset  of  menstruation, 
the  menopause  is  attended  by  marked  nervous  symptoms.  Byron 
Robinson  says  that  a  stormy  puberty  is  followed  by  a  stormy 
menopause.  These  various  changes  manifest  themselves  in  irri- 
tability of  temper,  melancholia,  hysteria  and  other  mental  dis- 
turbances of  different  varieties.  Insanity,  accompanying  the 
menopause,  has  been  noted  in  some  cases.  Hysteria  is  a  marked 
symptom.  The  sexual  appetite  becomes  inordinate,  in  some 
cases  leading  to  excesses.  The  patient's  entire  disposition  is 
changed,  she  frequently  becoming  peevish  and  fretful.  This, 
however,  is  not  found  in  every  case. 

These  various  reflex  troubles  depend  upon  the  strength 
of  the  parts  affected.  If  a  lesion  disturbs  the  innervation 
of  the  heart  then  the  exciting  cause,  the  circulatory  and  nervous 
changes  in  the  pelvic  viscera  will  weaken  it  more.  If  neck  le- 
sions exist  the  circulation  to  the  brain  is  altered,  often  to  a  patho- 
logical degree.  This,  coupled  with  the  changes  in  the  pelvic 
genitalia,  leads  to  diseased  conditions  or  perversions  ranging 
from  a  mere  idiosyncrasy  to  msanity.  The  same  may  be  said 
of  other  forms  of  reflexes.  There  is  usually  a  bony  lesion  affect- 
ing the  part,  whether  the  stomach,  lungs,  bowels,  or  cerebral 
circulation,  which  weakens  it  so  that  it  cannot  resist  the  ex- 
citing causes  which  are  at  work. 

The  DANGERS  of  the  menopause  are  the  tendency  to  hem- 
orrhage, and  onset  of  malignant  diseases,  principally  cancer 
of  the  uterus  and  breast.  Every  woman  knows  this  and,  on 
this  account,  if  there  is  an  abnormal  .condition  it  injuriously 
preys  on  her  mind.  On  the  other  hand  the  menopause  cures  a 
GREAT  MANY  PELVIC  DISEASES.  Dysmenorrhea  in  all  its  varied 
forms  disappears;  inflammatory  conditions  abate  on  account  of 
the  atrophic  changes;  fibroid  tumors  cease  their  growth,  or  atro- 


388  DISEASES  OF  WOMEN. 

phy  from  lack  of  nourishment;  various  ovarian  troubles  are 
cured,  thus  relieving  the  patient  of  pains  which  have  made  life  a 
burden.  Such  patients  hail  with  joy  the  approach  of  the  men- 
opause. 

The  diagnosis  of  the  approach  of  the  menopause  is  made 
by  noting  the  irregular,  scanty,  or  profuse  menstruation  and  pecu- 
liar reflex  symptoms  not  before  noticed  by  the  patient.  If  these 
symptoms  appear  in  a  woman  between  the  ages  of  forty  and  fifty, 
who  has  been  previously  healthy,  suspect  the  menopause  as  the 
cause. 

TREATMENT.  The  treatment  is  palliative,  that  is,  the 
various  symptoms  can  be  relieved  but  not  entirely  cured  until 
the  cessation  of  the  flow.  The  symptoms  should  be  treated  as 
they  arise  If  the  heart  is  weak,  strengthen  it  by  raising  the 
ribs  and  correcting  the  predisposing  weakness.  The  hot  flashes 
are  usually  controlled  by  a  spinal  treatment  and  by  work  applied 
to  the  pelvic  organs,  since  these  flashes  are  the  result  of  some  of 
the  pelvic  disturbances.  Vertigo,  headaches,  and  the  eye  and 
ear  derangements  can  be  helped  by  neck  treatment,  but  the  symp- 
toms can  not,  as  a  rule,  be  permanently  relieved  until  the  change 
of  life  is  past.  The  hemorrhage,  if  excessive,  is  stopped  by  treat- 
ment which  produces  uterine  contraction.  As  mentioned  above, 
the  menses  may  reappear  after  a  hard  treatment,  but  do  not  be 
alarmed  unless  the  hemorrhage  is  excessive  or  frequent,  since 
evil  results  seldom  follow. 

If  the  abnormal  conditions  of  the  change  of  life  are  due  to 
bony  lesions,  treatment  should  be  given  to  correct  these  lesions. 
In  cases  of  chronic  uterine  disease  these  lesions  are  common  and 
do  affect  the  menopause.  Lesions  which  affect  the  other  physir- 
ogical  functions  of  the  uterus  will  certainly  affect  the  menopause 
and  should  be  regarded  as  important  causes  in  cases  of  abnormal 
change  of  life. 


PHYSIOLOGICAL    PERIODS.  389 

The  premature  or  acquired  type  of  menopause  is  the  form 
that  most  frequently  calls  for  treatment.  The  natural  or  physio- 
logical type  is,  or  rather  should  be,  free  from  symptoms  severe 
enough  to  warrant  treatment.  The  produced  or  intentional 
type  is  brought  about  by  the  removal  of  the  ovaries  or  uterus. 
This  is  done  in  order  to  relieve  ovarian  or  uterine  disease,  dys- 
menorrhea or  menorrhagia,  lessen  the  growth  of  uterine  fibroids, 
or  to  cure  certain  diseases  which  are  supposed  to  depend 
on  a  diseased  condition  of  the  ovaries  or  uterus,  such  as  epilepsy, 
insanity  or  excessive  nervousness.  It  is  of  value  in  some  of  these 
cases,  especially  if  there  is  an  abuse  of  the  sexual  organs,  yet  I 
have  seen  many  cases  of  insanity,  epeilpsy  and  other  diseases  not 
even  benefited  and  some  even  made  worse  by  bringing  on  a  pre- 
mature menopause  by  ovariotomy.  The  cystic  ovary  is  the  kind 
most  often  operated  on. 

Premature  menopause  from  causes  other  than  operations 
such  as  shock  or  wasting  diseases,  seldom  produces  such  evil  effects 
as  the  above.  If  the  result  of  mental  shock ,  various  functional 
disorders,  cerebral  disturbances,  backache  and  nervousness  may 
follow.  I  recall  one  case  in  which  a  mental  shock  at  the  men- 
strual period  brought  on  a  premature  menopause  followed  by  a 
very  marked  chronic  eruption  and  ulceration  of  the  skin. 

Ovariotomy  performed  before  the  menopause  has  certain 
effects  that  are  fairly  constant.  Menstruation  usuallv  ceases 
at  once  if  both  ovaries  are  completely  removed.  Some- 
times for  a  while  vicarious  menstruation  and  molimina  fol- 
low. The  menstrual  molimina  are  most  pronounced,  and  are 
characterized  by  pain  over  the  ovaries,  in  the  breasts,  head,  back 
and  lower  limbs,  tinnitus  aurium,  vomiting,  fainting  and  labor- 
ed or  otherwise  disturbed  heart  beat.  These  symptoms  are  fol- 
lowed by  hot  and  cold  flashes,  or  even  flushings  of  the  skin  that 


390  DISEASES    OF    WOMEN. 

are  plainly  visible.  These  thermic  flashes  are  irregular  and  recur 
several  times  per  day.  Localized  perspiration,  a  sense  of  weak- 
ness and  thoracic  oppression,  leucorrhea  in  its  worst  form,  are 
present  and  the  appearance  of  "mannish  tendencies"  are  com- 
mon if  the  ovaries  are  removed  quite  early,  that  is  as  young  as  the 
age  of  twenty-five  years. 

The  local  effects  of  ovariotomy,  or  of  the  artificial  menopause 
induced  by  it,  are:  hyperemia  of  the  uterus  continuing  for 
several  months,  characterized  by  hemorrhages  of  varying  degrees, 
and  leucorrhea;  atrophy  and  softening  of  the  vaginal  walls,  on 
which  account  the  rugae  disappear,  the  walls  become  dry  and 
the  mucous  membrane  folded  or  prolapsed.  The  uterine  atro- 
phic changes  are  similar  to  those  in  the  normal  menopause,  but 
more  rapid,  obesity  develops,  the  sexual  function  is  perverted 
or  destroyed  followed  by  depression  of  spirits,  and  the  patient 
is  in  a  worse  condition  than  she  was  before  she  was  operated  on. 
In  other  cases  a  sense  of  drawing  or  contraction  appears  in  the 
groin  as  a  result  of  the  formation  of  scar  tissue  which  contracts. 
Sometimes  this  "pulling"  as  the  patient  describes  it,  is  very  pain- 
ful and  annoying. 

The  production  of  a  premature  menopause  by  ovariotomy 
is  indicated  in  a  few  cases,  but  in  most  cases  osteopathic  treat- 
ment does  away  with  the  necessity  of  an  operation.  In  cases  of 
chronic  disease  of  the  ovaries,  tubes  or  uterus,  which  do  not  re- 
spond to  treatment  after  a  thorough  trial,  and  which  cause  local 
pain,  menstrual  disturbances  or  reflex  phenomena  to  a  pathol- 
ogical extent,  an  operation  is  indicated,  but  such  cases  are  few. 

SENILITY  is  that  period  which  follows  the  change  of  life. 
It  is  a  period  of  repose  and  one  of  physiological  inactivity  of 
the  sexual  organs.  In  the  early  part  of  the  period,  malignant 
growths  are  prone  to  occur.     Any  abnormal  hemorrhage  of  the 


PHYSIOLOGICAL    PERIODS.  391 

uterus  should  be  carefully  investigated.  Prolapsus  is  frequently 
found,  but  causes  comparatively  little  trouble.  The  cases  of 
COMPLETE  PROCIDENTIA  are  most  frequently  found  during  this 
period.  The  patient  is  usually  free  from  the  ordinary  uterine  dis- 
turbances and  cancer  is  about  the  only  disease  to  be  feared.  Oc- 
casionally during  this  period  prolapsus  and  retroversion  produce 
marked  reflex  symptoms,  such  as  an  intense  backache,  headache 
or  queer  feelings  in  the  head,  loss  of  memory  and  symptoms  sug- 
gestive of  softening  of  the  brain.  Sometimes  fibroid  tumors 
appear  even  at  this  late  age,  but  only  in  cases  of  uterine  injury 
or  disease. 

OVULATION  is  the  process  which  includes  the  maturing  of 
the  Graafian  follicle,  its  rupture,  escape  of  the  ovum  and  its 
transmission  to  the  uterus,  although  it  may  drop  down  into  the 
peritoneal  cavity  and  there  perish.  Reed  says  "paradoxical  as 
it  may  appear,  it  may  be  well  said  that  nowhere  in  the  body  do 
we  have  a  physiologic  process  with  such  typical  pathologic  feat- 
ures as  are  found  in  ovulation."  He  further  states  that  "after 
a  Graafian  follicle  matures  there  is  a  rupture  and  hemorrhage  fol- 
lowed by  formation  of  cicatricial  tissue."  It  begins  at  puberty, 
or  rather,  puberty  depends  upon  the  beginning  of  ovulation.  This 
occurs  between  the  thirteenth  and  fifteenth  years. 

In  most  animals,  ovulation  is  a  periodic  process  occuring 
in  certain  seasons  and  marked  by  increased  sexual  activity.  In 
the  woman,  and  many  domesticated  animals,  this  relation  does 
not  exist  and  ovulation  occurs  at  no  stated  period.  Some  be- 
lieve that  it  is  a  periodic  phenomenon  occurring  every  month. 
This  is  the  time  of  most  common  occurrence  but  it  may  take  place 
at  any  other  time.  This  has  been  proven  by  post  mortem  exami- 
nations revealing  fresh  scars  on  the  ovaries  at  the  intermenstrual 
time,   these    indicating    the    rupture    of   the   Graafian    follicles. 


392  DISEASES    OF    WOMEN. 

Throughout  the  entire  fruitful,  or  childbearing  period,  the  devel- 
opment and  rupture  of  the  Graafian  follicles,  which  discharge 
their  ova,  are  continuously  occurring.  It  may  occur  independ- 
ently  of   menstruation,  but  menstruation  certainly  depends 

ON  THE    PHYSIOLOGICAL   ACTIVITY   OF  THE   OVARY. 

The  Graafian  follicles  begin  to  swell  and  enormously 
increase  in  size  just  prior  to  their  rupture.  As  soon  as  rupture 
takes  place  the  ovum  thrown  out  upon  the  peritoneal  aspect  of 
the  ovary,  is  then  caught  up  by  the  fimbriated  extremity  of  the 
Fallopian  tubes  and  transmitted  by  means  of  the  ciliated  epithe- 
lium into  the  uterus.  Some  say  that  the  fimbriae  are  erectile 
and  surround  the  ovary,  while  others  say  that  the  suction  pro- 
duced by  the  motion  of  the  cilia,  draws  the  ovum  directly  into 
the  tube.  It  is  carried  directly  to  the  ampulla,  or  largest  part  of 
the  tube,  at  which  point  impregnation  is  supposed  to  take  place. 

In  a  DISEASED  CONDITION  of  the  ovaries,  ovulation  is  pre- 
vented or  interfered  with,  which  results  in  some  form  of  men- 
strual disorder.  During  lactation  and  pregnancy  the  process 
is  probably  at  a  standstill,  although  cases  of  much  sexual  irrita- 
tion following  parturition  frequently  excites  activity  and  brings 
on  ovulation  and  menstruation.  It  is  also  stopped  by  the  re- 
moval of  the  entire  ovary  and  usually  by  removal    of   the  uterus, 

although  MENSTRUATION  CONTINUES  LONGER  AFTER  REMOVAL  OF 
THE  UTERUS  THAN  OF  THE  OVARY.  IMPREGNATION  is  mOSt  LIKE- 
LY TO  OCCUR,  if  COITION  takes  place  immediately  before  or  after 
menstruation.  Impregnation  may  occur  at  any  time,  although 
there  are  about  four  days  in  a  month  in  which  it  is  not  likely  to 
take  place,  these  being  from  the  eighteenth  to  the  twenty- 
second  day  following  the  menstrual  period.  The  ovum  may  stay 
in  the  tubes  and  uterus  for  some  time  and  still  retain  the  power  of  be- 
coming impregnated.    The  same  might  be  said  of  the  spermatozoa. 


PHYSIOLOGICAL    PERIODS.  393 

MENSTRUATION  is  a  discharge  of  blood  from  the  uterus 
aiid  Fallopian  tubes,  accompanied  by  the  shedding  of  the  super- 
ficial layers  of  the  mucous  membrane,  or  surface  epithelium  from 
it,  OCCURRING  DURING  the  period  of  a  woman's  sexual  activity, 
from  puberty  to  the  menopause,  every  lunar  month  or  twenty- 
eight  days.  It  is  also  called  menorrhea,  catamenia.  monthly 
sickness,  turns,  periods,  sick  time,  courses  or  menses. 

Various  theories  have  been  set  forth  to  explain  this  phe- 
nomenon. The  old  writers  supposed  that  it  was  due  to  a  woman's 
uncleanliness,  and  menstruation  was  thought  to  be  an  effort  on 
the  part  of  nature  to  rid  herself  of  noxious  elements,  ^"ery  queer 
ideas  prevailed,  such  as  that  a  drop  of  menstrual  flow  would  fade 
a  flower,  and  that  a  menstruating  woman  in  a  dairy  would  turn 
milk  sour.  Another  gives  as  a  cause,  a  plethoric  state  of  the 
body,  the  congested  condition  being  relieved  by  the  menstrual 
flow.  The  best  theory  is  that  it  is  a  natural  process,  and  one  of 
the  functions  of  the  female  organs.  It  prepares  a  nidus  for  the  re- 
ception of  an  impregnated  ovum  and  should  be  no  more  of  a 
mystery  than  ovulation.  The  part  we  are  most  interested  in  is 
the  disturbances  of  this  function,  not  the  vague  theories  offered 
for  its  explanation.  The  onset  is  influenced  by  race,  climate, 
heredity,  environments,  food  and  mode  of  living.  A  warm  cli- 
mate, HIGHLY  seasoned  food,  excitable  surroundings,  that  is 
sexual  excitements,  association  with  the  other  sex.  erotic 
pictures  or  impure  literature,  all  tend  to  bring  menstruation 
on  earlier  than  if  these  conditions  had  not  existed.  Sexual 
passion  is  stronger  in  some  than  in  others,  menstruation  ap- 
pearing late  in  those  in  whom  it  is  not  w^ell  developed. 
In  those  in  whom  sexual  passion  is  strong,  development  is  early 
and  the  menses  appear  at  an  early  age.  Early  menstruation 
generally   means   a  profuse   discharge,  disordered   menstruation 


394  DISEASES   OF    WOMEN. 

and  a  late  menopause.  Late  menstruation  means  scanty  and 
painful  menstruation  and  sterility.  At  first  the  menstruation  is 
usually  irregular  and  requires  at  least  a  year  before  regularity 
is  established.  The  factors  which  enter  into  the  menstrual  func- 
tion are    (1)  ovarian  activity,    (2)  ovarian  congestion.     (3) 

UTERINE  congestion,  (4)  UTERINE  CONTRACTION,  (5)  a  MEN- 
STRUAL FLUID  TO  BE  EXPELLED,  and  (6)  a  PASSAGEWAY.  AlL 
MENSTRUAL    DISORDERS    RESULT    FROM    DISTURBANCE    OF    ONE    OR 

MORE  of  these  factors. 

MENSTRUAL  MOLIMINA  include  the  local  and  reflex  sub- 
jective symptoms.  Just  preceding  the  flow  there  is  a  sense  of 
WEIGHT  and  HEAVINESS  in  the  pelvis  and  limbs.  This  is  the  re- 
sult of  the  congestion  which  precedes  menstruation.  The  breasts 
are  tender  and  full,  sometimes  a  slight  secretion  taking  place. 
The  THYROID  gland  swells  and  the  mucous  membrane  of  the 
throat  becomes  congested.  It  is  a  well  known  fact  that  singers 
have  often  cancelled  engagements  which  occurred  at  the  men- 
strual period,  since  their  voices  were  affected;  either  the  voice 
becoming  hoarse,  husky  and  changed  in  quality,  or  is  entirely 
lost  at  that  time.  Pigmentation  of  the  skin  occurs,  the  face 
becoming  more  sallow  with  dark  rings  under  the  eyes.  Herpes 
or  blisters  are  found  on  the  lips;  also  they  frequently  appear  on 
the  face,  giving  it  a  mottled  appearance.  The  acne  of  menstrua- 
tion are  perhaps  due  to  some  reflex  disturbance  of  the  fifth  cranial 
nerve,  as  it  has  on  it  several  sympathetic  ganglia. 

Nervous  changes  are  noticeable,  the  patient  being  changed 
in  disposition ;  there  is  also  loss  of  energy  and  various  other  symp- 
toms of  a  disturbed  nerve  supply.  Hysteria  is  more  prevalent 
at  this  time  than  at  any  other,  and  if  the  patient  is  subject  to 
epilepsy  or  hystero-epilepsy  the  attacks  are  harder  and  occur 
oftener  at  this  time. 


PHYSIOLOGICAL    PERIODS.  395 

Leucorrhea  is  increased  in  amount;  pruritus  is  also  pres- 
ent in  some  cases  and  gives  the  patient  a  great  deal  of  trouble, 
especially  during  the  latter  part  of  menstruation.  There  is 
chronic  backache,  headache,  the  heart  is  subject  to  palpitation 
ami  there  is  a  general  feeling  of  lassitude,  tenderness  and  aching 
over  the  entire  body. 

THE  FLOW  consists,  for  the  greater  part,  of  blood  which  is 
supplemented  by  the  mucous  secretions  and  epithelial  cells.  It 
is  ALKALINE  in  character  and  has  a  peculiar  odor.  In  normal 
cases  it  is  dark  in  color  and  free  from  clots.  There  should  also 
be  absence  of  pain,  but  this  condition  is  rarely  found. 

The  quantity  has  been  estimated  at  from  four  to  six  ounces, 
but  it  has  quite  a  physiological  variation.  This  can  be  estimated 
by  the  number  of  napkins  used.  If  the  patient  has  to  change  the 
napkin  more  than  two  times  per  day  during  the  height  of  the 
flow,  the  QUANTITY  is  excessive.  The  author  has  seen  cases  in 
which  tampons  were  used  to  collect  or  absorb  the  menstrual  flow. 
Such  a  practice  long  continued  results  in  a  dilated  vagina,  fol- 
lowed by  uterine  displacement  such  as  retroversion  and  pro- 
lapsus. 

The  length  of  the  flow  is  on  an  average  about  four  days,  but 
may  be  lessened  to  two  days  or  increased  to  as  many  as  six,  and 
yet  be  normal  for  that  individual. 

The  source  of  the  flow  is  from  the  mucous  membrane  lining 
the  uterus  and  the  Fallopian  tubes,  and  a  few  authors  say  that 
some  comes  even  from  the  ovary.  A  destructive  change  occurs 
in  the  endometrium  which  results  in  its  distintegration  and  the 
discharge  of  at  least  a  part.  The  uterine  cavity  is  soon  coated 
with  a  new  endometrium  which  furnishes  a  fresh  nidus  for  the 
fixation  and  nutrition  of  the  impregnated  ovum.  It  seems  that 
menstruation  is  a  systemic  process,  that  is  one  not  confined  to  the 


396  BISEASES    OF    WOMEN. 

pelvic  organs,  although  they  are  the  prime  factors.  The  whole 
system  undergoes  a  change,  the  formation  and  escape  of  the 
ovum,  its  reception  into  the  uterus,  and  the  local  symptoms  be- 
ing only  a  local  expression  of  the  general  condition. 

Cessation  of  the  flow  occurs  on  an  average  at  the  age  of 
forty-five,  yet  there  are  notable  exceptions  to  this  rule.  Local 
examinations  and  treatments  should  be  avoided,  if  possible, 
during  the  flow,  also  coition  should  be  prohibited  at  this  time. 


GENERAL    DISORDERS    OF    MENSTRUATION.  397 


GENERAL  DISORDERS  OF  MENSTRUATION. 


DISORDERS  OF  MENSTRUATION.  The  disorders  of  men- 
struation form  the  most  frequent  and  important  of  complaints 
of  the  female.  It  is  rare  to  find  a  woman  who  has  no  disorder  at 
the  menstrual  period;  in  whom  the  menstrual  period  is  free  from 
PAIN,  of  normal  amount  and  length  of  flow.  These  disorders  do 
not  constitute  disease  in  themselves,  but  are  results  or  symp- 
toms of  the  various  uterine  displacements  and  inflammation, 
and  are  very  important  in  that  they  are  so  common.  Habits, 
mode  of  dress  and  fashion,  are  all  combined  to  make  the  menstrual 
period  the  "sick  time"  instead  of  the  "well  time"  as  it  should  be. 

The  menses  may  be  absent,  which  is  called  amenorrhea. 
The  other  forms  are  scanty  menstruation;  Menorrhagia  or 
too  profuse  flow;  painful  menstruation  or  dysmenorrhea. 
The  flow  may  come  from  another  part  of  the  body  and  is  then 
called  vicarious  menstruation;  or  it  may  begin  too  early,  in  which 
case  it  is  called  precocious  menstruation.  Hemorrhage  from  the 
uterus  at  other  times  than  the  menstrual  period  is  called  met- 
rorrhagia and  does  not  belong  to  the  disorders  of  menstruation. 
There  may  also  be  retarded  menstruation,  or  it  may  become  sup- 
pressed or  irregular. 

AMENORRHEA,  as  the  word  implies,  means  absence  of  a 
menstrual  discharge.  It  may  exist  in  one  of  two  forms;  the  pri- 
mary form,  called  the  emansio  mensium;  and  the  secondary  form 
which  is  called  suppressio  mensium.  The  primary  form  is 
found  in  cases  in  which  the  menses  have  never  appeared  although 
the  patient  is  of  the  proper  age,  while  the  secondary  form  occurs 
in  cases  in  which  menstruation  has  once  started  but  has  ceased 


398  DISEASES    OF    WOMEN. 

from  some  cause  or  other.  At  certain  periods  there  is  a  physi- 
ological amenorrhea,  viz.,  during  pregnancy,  lactation,  before 
puberty  and  after  the  menopause. 

CAUSES.  The  causes  of  the  primary  form,  or  true  amen- 
orrhea, are  the  absence  of  the  reproductive  organs,  and  the  fail- 
ure of  these  organs  to  develop  from  their  immature  state  which 
exists  in  infancy  to  the  mature  state  found  in  maturity.  Ab- 
sence of  the  ovaries  and  tubes;  absence  or  imperfect  develop- 
ment of  the  uterus,  or  what  is  called  an  "infantile  uterus;" 
and  absence  or  atresia  of  the  vagina  are  the  usual  causes  of  the 
primary  form. 

An  imperforate  hymen  prevents  the  external  appearance 
of  the  menstrual  flow  and  the  case  is  regarded  as  one  of  amen- 
orrhea, but  it  should  be  called  concealed  menstruation. 

Overwork  at,  or  just  preceding  the  time  the  menses  should 
be  established  frequently  prevents  the  development  of  the  pel- 
vic organs,  causing  amenorrhea;  or  it  depletes  the  system,  leav- 
ing, the  patient  without  enough  blood  to  begin  the  menstrual 
flow.  Diseases,  especially  of  the  debilitating  class,  occurring  at 
this  time  also  prevent  menstruation  in  a  similar  way.  Changes 
in  climate  and  environment  frequently  cause  amenorrhea,  as 
is  seen  in  emigrants. 

THE  SECONDARY  or  suppressio  mensium  form  of  amenor- 
rhea is  due  to  a  great  many  causes.  This  form  hicludes  the 
cases  in  which  the  flow  has  been  stopped  after  puberty  has  been 
established,  or  suppressed  after  the  menses  have  once  begun. 

Since  the  flow  comes  principally  from  the  mucous  membrane 
lining  the  Fallopian  tubes  and  uterus,  it  follows,  that  anything 
causing  a  lack  of  blood  to  these  parts,  or  producing  a  sudden  con- 
traction of  the  muscle  fibers  of  the  uterus,  will  cause  a  cessation 
of  the  flow.     On  account  of  the  ovaries  exerting  a  stimulus  over 


GENERAL   DISORDERS    OF    MENSTRUATION.  399 

the  other  pelvic  organs,  and  since  they  in  reality  control 
menstruation,  any  disease  impairing  their  function  will  cause 
disordered  menstruation,  most  commonly  amenorrhea.  Lesions 
in  the  lower  dorsal  region,  affecting  the  ovaries,  may  cause 
amenorrhea.  These  lesions  usually  consist  of  a  subluxated  ver- 
tebra, or  a  STIFFENED  CONDITION  of  the  spine  or  a  displaced  lower 
rib,  which  shut  off  the  nerve  force  to  the  ovaries  that  is  neces- 
sary to  the  proper  performance  of  their  function,  which  condi- 
tion results  in  the  absence  of  ovulation  and  menstruation.  The 
OVARIES  may  be  inflamed,  or  some  growths  may  have  appeared 
on  them  such  as  a  cyst  or  fibroid  tumor.  Uterine  displace- 
ments displace  the  ovaries  and  interfere  with  their  function.  If 
this  loss  of  function  is  complete  enough,  the  influence  of  the 
ovaries  over  the  uterus  ceases  and  menstruation  stops. 

In  the  economy  of  nature  there  is  not  enough  blood  to  carry 
on  both  the  vital  functions  and  menstruation.  Since  the  blood 
is  used  to  carry  on  the  vital  functions,  any  debilitating  dis- 
ease that  impairs  its  quality  or  lessens  the  quantity,  if  great 
enough,  will  cause  amenorrhea.  In  such  cases  menstruation 
gradually  ceases,  that  is,  the  flow  becomes  more  scant  each  time 
until  it  stops  completely.  In  order  that  there  ma}''  be  normal 
menstruation  two  things  are  necessary:  Good  blood  and  un- 
impaired NERVOUS  'energy.  Debilitating  diseases  impair 
the  quality  of  the  blood  and  vice  versa.  No  better  illustration 
of  this  can  be  found  than  the  prevalence  of  amenorrhea  in  tuber- 
cular patients;  phthisis  being  most  frequent.  It  is  a  popular 
OPINION  that  if  a  girl  ceases  to  menstruate,  it  is  a  foregone  con- 
clusion that  she  is  going  into  consumption.  As  a  rule  every  one 
that  has  tuberculosis  has  amenorrhea,  but  it  does  not  necessarily 
follow  that  amenorrhea  is  a  symptom  of  consumption.  Anemia, 
chlorosis,  malaria,  syphilis  and  the  strumous  diathesis  are  dis- 


400  DISEASES  OF   WOMEN. 

eases  and  conditions  that  are  accompanied  or  followed  by  amenor- 
rhea. The  ACUTE  DISEASES  also  cause  at  least  a  temporary  cessa- 
tion of  menstruation.  This  is  most  marked  in  the  exanthemata. 
In  short,  any  disease  or  condition  that  impairs  the  quality  of 
THE  blood  tends  to  produce  amenorrhea,  and  does  in  most 
cases,  if  the  disease  becomes  chronic. 

Overwork,  such  as  hard  study,  draws  the  blood  to  the  part 
that  is  used  most  and  leaves  the  pelvic  organs  anemic,  in  this  way 
causing  amenorrhea.  This  often  occurs  in  students,  usually 
causing  very  little  discomfort,  and  should  not  be  rp:garded  as 
important,  since  the  menses  usually  recur  as  soon  as  the  patient 
ceases  to  work. 

Sudden  cessation  of  the  flow  is  due  to  getting  wet,  or  to  other 
forms  of  exposure,  or  it  may  be  due  to  psychic  causes  such  as  the 
receipt  of  unexpected  news,  fright,  grief,  or  extreme  joy.  The 
shock  to  a  patient,  when  menstruating,  caused  by  news  of  the 
death  of  a  relative  or  friend  is  the  most  common  of  these  causes. 
The  writer  has  treated  many  such  cases,  in  some  of  which,  the 
melancholic  type  of  insanity  developed. 

Any  injury  or  accident  which  causes  marked  uterine  con- 
traction will  stop  the  flow.  A  hard,  stimulating  treatment 
applied  to  the  lumbar  region  will  in  some  cases,  stop  the  normal 
flow;  in  others  it  will  bring  on  the  period.  Then  the  question 
often  arises,  should  we,  or  can  we,  stop  the  normal  menses  by 
treatment?  In  the  first  place  we  should  not;  and  in  the  second 
place,  it  can  be  stopped  if  the  treatment  is  so  hard  that  it  brings 
on  severe  uterine  contraction.  Menorrhagia  can  be  controlled 
by  this  kind  of  treatment,  which  results  in  a  temporary  closing 
of  the  OS  uteri.  The  more  nearly  normal  the  case  the  less  the 
effect  of  such  treatments.  Also  there  is  a  tendency  on  the  part 
of  the  organism  to  resume   normal  activity,  hence  the   same 


GENERAL   DISORDERS    OF    MENSTRUATION.  401 

treatment  given  for  opposite  conditions  often  result  in  a  relief 
or  even  cure.  Lesions  of  the  pelvic  bones  shutting  off  or  dimin- 
ishing the  blood  supply  to  the  pelvic  organs,  will  cause  amenor- 
rhea if  the  condition  lasts  for  any  length  of  time.  The  most 
common  of  these  lesions  is  a  forward  slip  of  the  ilium  or  back- 
ward slip  of  the  sacrum.  Most  lesions  of  the  pelvic  bones  have  a 
direct  effect  on  the  uterus,  that  is,  they  cause  a  passive  conges- 
tion of  the  uterus. 

Acute  flexion  may  cause  amenorrhea,  but  more  commonly 
causes  dysmenorrhea.  Obesity  is  often  stated  as  a  cavise  of  amen- 
orrhea in  young  girls,  but  I  think  that  just  the  reverse  of  this 
condition  exists,  that  is,  obesity  is  the  result  of  cessation  of  ovarian 
activity.  The  same  condition  takes  place  after  the  menopause 
whether  the  menopause  is  natural  or  acquired.  Menstruation 
usually  ceases  before  obesity  occurs,  or  at  least  before  it  has  ex- 
isted very  long.  In  obese  people  the  generative  organs  are 
not  so  fully  developed  as  in  those  of  a  bony  make-up.  This  also 
holds  true  in  the  male,  the  generative  organs  as  stated  above  are 
usually  found  to  be  small  in  fleshy  persons.  The  point  is  this, 
the  obese  are  not  so  strong  sexually  and  the  ovaries  in  their  weak- 
ened condition,  do  not  exert  the  proper  influence  over  the  uterus, 
hence  the  disturbed  menstruation  or  amenorrhea. 

SYMPTOMS.  The  most  easily  recognizable,  and  the  most 
important  symptom  is  absence  of  the  menstrual  flow,  yet 
not  every  case  in  which  there  is  absence  of  the  flow  is  one  of 
pathological  amenorrhea,  although  it  happens  during  maturity. 
If  this  occurs  in  a  girl  who  has  passed  the  age  at  which  the  flow 
should  have  started  but  did  not,  it  is  the  primary  form.  In 
some  the  symptoms  may  be  insignificant,  but  in  others  there  is 
frequently  found  headaches  in  the  top  of  the  head,  hot  and  cold 
flashes,  sense  of  fullness  and  pain  in  the  abdomen,  nervous  dis- 


402  DISEASES    OF    WOMEN. 

orders  and  gastric  disturbances.  In  some,  there  are  all  the  symp- 
toms of  menstruation  except  the  appearance  of  the  discharge. 
Look  at  the  patient.  Inspection  often  readily  reveals  the 
true  condition.  The  complexion  changes  in  color,  pimples  ap- 
pear on  the  face,  dark  rings  under  the  eyes,  tenderness  of  the 
mammary  glands,  and  there  is  a  dull,  achy  feeling  which  is  so 
commonly  associated  with  menstruation.  Such  symptoms 
occurring  at  regular  intervals  make  up  the  condition  called  moli- 
mina.  In  these  cases  atresia  should  be  looked  for,  it  being  ascer- 
tained by  a  digital  examination  or  by  the  use  of  a  probe  or  sound. 
An  imperforate  hymen  can  be  diagnosed  by  inspection.  The 
external  genitals  are  small,  and  the  cervix  long  and  pointed,  in- 
dicating non-development,  or  the  "infantile"  type.  The  ovaries 
are  small  and  the  breasts  rudimentary.  Patients  belonging  to 
this  class  are  anemic,  have  morbid  appetites  and  are  very  bash- 
ful  and  listless. 

The  secondary  form  is  characterized  by  the  stopping  of 
menstruation  after  its  appearance  at  puberty.  The  symp- 
toms are  very  slight  in  some  cases,  while  in  others  they  are  mark- 
ed, unless  due  to  debilitating  diseases.  Not  even  molimina  are 
found  in  most  cases.  These  cases  are  anemic  and  weak,  with 
loss  of  strength  and  ambition;  functional  heart  troubles  are  fre- 
quent and  the  patient  has  palpitation  and  dyspnea  on  the  least 
exertion.  Digestion  and  nutrition  are  impaired,  there  being 
anorexia,  flatulency,  constipation  and  dyspepsia  with  its  varied 
symptoms.  Sleep  is  not  good  and  the  patient  is  unrefreshed  by 
it.  Leucorrhea  is  increased  in  amount,  and  in  some  cases  is  sup- 
posed to  take  the  place  of  the  menstrual  flow. 

The  symptoms  of  suppressio  mensium  due  to  exposure  or 
lesions  are  backache;  headache,  sense  of  fullness  and  weight  in 
the  pelvis,  tingling  and  tenderness  in  the  breasts;  in  short,  the 


GENERAL   DISORDERS   OF    MENSTRUATION.  403 

patient  has  all  symptoms  of  the  flow  without  its  appearance. 
These  symptoms  are  exaggerated  at  the  regular  time  for  the  menses 
and  cause  quite  a  great  deal  of  discomfort  and  pain.  In  such 
cases  the  flow  may  be  concealed,  that  is  it  may  remain  in  the 
uterus  for  several  months  and  then  be  discharged  in  the  form  of 
black  clots  and  in  great  quantities.  The  writer  recently  had  a  case 
of  this  kind.  The  patient  had  missed  six  monthly  periods  and 
there  was  quite  a  marked  enlargement  of  the  abdomen.  In 
getting  a  history  of  the  case  it  was  found  that  she  had  been  in  a 
similar  condition  several  times  previously,  and  with  this  and  the 
absence  of  local  and  reflex  symptoms,  pregnancy  was  excluded. 
On  examination  the  uterus  was  found  enlarged  and  the  os  patu- 
lous. It  was  suspected  that  she  had  retention  of  the  menses, 
that  is  a  hemometra  and  possibly  physometra,  which  later  the 
case  proved  to  be.  In  this  case  there  were  the  symptoms  of 
anemia,  poor  nutrition  and  a  general  loss  of  strength. 

Another  case  of  amenorrhea  of  a  different  character  came 
to  my  notice.  A  young  girl  had  missed  two  menstrual  periods, 
but  few  molimina  were  present.  At  the  fourth  menstrual  period 
the  uterus  seemed  to  go  into  labor  and  after  a  while  large, 
FLESHY  MASSES  were  expelled.  The  patient  apparently  re- 
covered but  the  condition  returned  within  a  year  with  similar 
symptoms.  After  several  months'  treatment  the  case  was  cured, 
having  been  diagnosed  as  one  of  uterine  mole.  Ordinarily,  moles 
result  from  a  diseased  condition  of  the  chorion,  hence  complicate 
pregnancy,  but  in  this  case  no  history  or  indication  of  pregnancy 
could  be  obtained  although  it  was  undoubtedly  a  case  of  uterine 
mole.  After  the  removal  of  the  fleshy  mass,  the  menses  came  on 
in  normal  manner  and  contmued  regular. 

If  the  menses  are  simply  delayed  there  will  be  headache, 
BACKACHE,  with  a  general  soreness  and  uncomfortable  feeling. 


404  DISEASES   OF   WOMEN. 

The  sudden  suppression  of  the  flow  from  exposure  or  emotional 
influences,  gives  rise  to  an  acute  congestion  and  inflammation  of 
the  uterus.  The  blood  is  forced  back  through  the  Fallopian  tubes 
into  the  peritoneal  cavity,  ami  sets  up  a  peritonitis.  The  pa- 
tient has  fever,  extreme  tenderness  over  the  abdomen  and  in- 
tense pain.  In  other  cases  the  symptoms  are  not  so  marked, 
there  being  only  a  general  feeling  of  discomfort. 

A  sudden  strain,  slip  or  fall  during  menstruation,  bringing 
on  a  stoppage  of  the  flow,  is  followed  by  similar  symptoms.  The 
sudden  suppression  in  such  cases  is  due  to  contraction  of  the 
uterus,  especially  the  cervix,  which  closes  the  opening  of  the  blood 
vessels,  and  occludes  the  outlet  of  the  uterus.  In  cases  due  to 
overwork,  either  physical  or  mental,  the  amenorrhea  will  come 
ON  GRADUALLY,  with  few,  if  any,  symptoms  referred  to  the 
pelvic  organs.  The  extra  blood  is  used  up  in  the  development 
of  the  brain  or  muscles  and  little  or  none  is  left  for  menstruation. 
In  such  cases  the  onset  is  gradual  and  should  cause  no  alarm. 

DIAGNOSIS.  The  most  important  question  pertaining  to 
diagnosis  is  whether  the  amenorrhea  is  physiological  and  due 
to  pregnancy,  either  normal  or  ectopic,  or  pathological  and 
the  result  of  disease.  If  it  is  physiological  and  due  to  pregnancy, 
the  symptoms  of  pregnancy  will  be  present.  The  most  common 
of  the  EARLY  indications  of  pregnancy  are  morning  nausea  and 
vomiting,  mammary  changes  in  which  the  primary  areolae  form, 
followed  by  the  secondary  areolae,  tingling  of  the  breasts 
with  progressive  enlargement  accompanied  in  many  cases  by 
secretion  of  milk;  ptyalism,  flattening  followed  by  enlargement 
of  the  abdomen ;  softening  of  the  cervix ;  change  in  position  of  the 
uterus,  it  at  first  becoming  anteflexed  or  anteverted,  followed 
by  ascent;  Hegar's  sign;  and  the  inverted  jug  shaped  appear- 
ance   of    the    uterus.     If    these   symptoms    are  present  in  addi 


GENERAL    DISORDERS    OF    MENSTRUATION.  405 

tion  to  amenorrhea  there  is  probably  pregnancy,  but  a  sure  diag- 
nosis can  not  be  made  until  some  of  the  positive  signs  of  preg- 
nancy are  obtained.  The  sure  signs  of  pregnancy  are  fetal 
heart  beat,  ballottement  and  quickening,  which  signs  can 
not  be  obtained  with  certainty  before  the  twentieth  week. 

If  amenorrhea  is  found,  consider  the  age  of  the  patient,  also 
her  occupation  and  habits.  If  above  the  age  of  forty,  it  may  be 
the  menopause  approaching;  or  if  the  patient  is  a  hard  mental 
worker  it  is  the  result  of  using  the  blood  for  the  development  of 
the  brain  and  leaving  little  or  none  for  the  menstrual  function. 
In  getting  the  history  inquire  as  to  the  stoppage,  whether  sudden 
or  after  an  exposure,  fall  or  strain,  or  whether  it  came  on  grad- 
ually. Consider  the  appearance  and  nourishment  of  the  patient, 
since  it  is  so  frequently  associated  with  anemia  and  debilitating 
diseases. 

In  cases  in  which  there  are  no  symptoms  or  signs  of  mens- 
truation occurring  at  stated  or  regular  intervals,  physiological 
amenorrhea  exists,  and  the  patient  needs  no  treatment  to  bring 
on  the  flow,  such  a  treatment  being  injurious  rather  than 
beneficial.  On  the  other  hand  in  cases  of  amenorrhea  in  which 
there  is  a  single  sign  or  symptom  recurring  at  regular  intervals, 
especially  every  fourth  week,  nature  is  attempting  to  establish 
the  menstrual  flow  and  such  efforts  should  be  aided.  Such  cases 
constitute  pathological  amenorrhea  and  the  establishing  of  the 
regular  menstrual  flow  will  relieve  all  symptoms. 

PROGNOSIS.  The  prognosis  depends  upon  the  general 
health  of  the  patient,  mode  of  onset  and  length  of  time  the  con- 
dition has  existed.  In  a  person  otherwise  health}-  the  prognosis 
is  very  good.  If  there  is  some  debilitating  disease  it  is  not  so 
good.  If  congenital,  usually  it  is  good  unless  there  is  absence  of 
an  organ;  if  due  to  atresia,  stenosis  or  an  imperforate  hymen  it  is 


406  DISEASES    OF    WOMEN. 

favorable  since  an  operation  will  remove  the  obstruction.  Cases  of 
acute  suppRESSio  mensium,  in  which  the  flow  stopped  before 
the  third  day,  can  be  relieved,  and  the  flow  started,  if  treat- 
ment is  given  within  twenty-four  hours  after  the  stoppage  of  the 
flow.  I  have  had  cases  in  which  the  flow  had  stopped  on  the  first 
day,  remaining  absent  five  daj^s,  and  was  then  brought  on  by 
osteopathic  treatment,  but  as  a  rule  it  can  not  be  started  after  it 
has  stopped  for  so  long  a  time. 

TREATMENT.  The  treatment  of  amenorrhea  due  to  an  ob- 
struction such  as  an  atresia  or  an  imperforate hymenis  surgical, 
an  operation  being  necessary.  In  cases  of  non-development, 
treatment  applied  to  the  lesion  which  causes  the  trouble  by  shut- 
ting off  the  nerve  supply  to  the  organs,  is  beneficial  and  sometimes 
curative.  These  lesions  are  found  from  the  eighth  to  the 
twelfth  dorsal  vertebra,  in  the  lower  lumbar  region,  sacrum  and 
innominates.  Freeing  the  nerves  emanating  from  the  spinal  cord 
in  the  lower  dorsal  region,  is  very  helpful.  This  can  be  accom- 
plished by  springing  the  spine,  separating  the  vertebrae  if  they 
are  grown  together  making  the  spine  stiff,  and  by  correcting  the 
muscular  lesions.  I  regard  spinal  lesions  the  most  important, 
since  they  affect  ovarian  activity  and  are  the  true  causes  of  the 
disease. 

In  cases  of  amenorrhea  due  to  constitutional  diseases,  do 
not  try  to  bring  on  the  flow  by  treatment  applied  to  the  pelvic 
organs.  It  will  be  useless,  and  again  it  does  no  good  to  bring  on 
the  menses,  even  harm  being  sometimes  produced.  Nature  has 
tried  to  preserve  all  the  blood  possible  by  stopping  the  menstrual 
flow.  The  fault  is  not  in  the  pelvic  organs  but  in  the  amount  and 
quality  of  the  blood.  If  there  is  plenty  of  good  pure  blood  and 
amenorreha  exists,  then  the  fault  may  be  in  the  generative  or- 
gans  and  treatment  should  be   directed  to   them,  otherwise  it 


GENERAL    DISORDERS    OF    MENSTRUATION.  407 

should  "not.  Treatment  should,  as  in  all  cases,  be  applied  to  the 
cause  of  the  trouble.  In  this  case  increase  the  quantity  and 
IMPROVE  the  quality  of  the  blood  by  giving  the  patient  plenty  of 
fresh  air,  outdoor  exercise,  a  sufficient  ciuantity  of  good  nutri- 
tious food,  and  osteopathic  treatment  applied  to  the  blood  form- 
ing organs,  such  as  the  liver,  spleen,  etc.  The  ribs,  if  down, 
should  be  raised,  since  neurasthenia,  anemia, etc..  result  from  their 
displacement.  In  short,  correct  lesions  affecting  the  abdominal 
organs.  Drug  physicians  usually  prescribe  stimulants  such  as 
iron,  quinine,  strychnine  and  other  inorganic  poisons,  yet  Byron 
Robinson  says  "We  have  no  known  drug  which  will  restore  the 
flow."  Do  they  nourish?  No,  there  is  no  food  in  them.  Do 
they  increase  the  amount  of  nerve  force  in  the  body?  No,  they 
really  weaken  it  by  drawing  on  the  reserve  nerve  force  of  the  body. 
Then  what  do  they  do?  They  stimulate,  and  that  is  all.  What 
USE  has  the  body  for  anything  introduced  into  the  stomach  un- 
less it  counteracts  a  poison  that  may  be  there,  or  can  be  absorbed 
as  a  food?  None,  and  the  poor  stomach  is  made  to  suffer  the 
effects  of  strong  inorganic  drugs  not  only  for  the  sake  of  various 
uterine  troubles,  but  even  diseases  of  more  remote  organs.  Of  all 
the  drugs  that  do  so  much  harm  I  regard  the  mineral  or  inorganic 
compounds  the  worst,  since  no  nutrition  is  found  in  them  and 
they  actually  destroy  the  lining  membrane  of  the  stomach.  When 
I  have  a  patient  that  requires  iron  I  prescribe  it.  but  in  a  differ- 
ent form.  Fruits,  especially  those  highly  colored,  such  as  black- 
berries and  strawberries,  abound  in  iron  which  is  in  an  organic 
form  and  can  be  absorbed  and  used  to  build  up  the  hemoglobin 
in  the  blood.  Red  apples  eaten  with  the  peelings  on,  are  espec- 
ially good,  most  of  the  iron  being  in  the  peeling.  This  is  the  best 
way  to  administer  drugs,  that  is,  in  the  form  of  a  natural  food. 

It  is  far  more  agreeable  to  the  palate  and  better  for  THE 


408  DISEASES    OP    WOMEN. 

STOMACH.  In  anemic  and  chlorotic  patients  suffering  frtnii  men- 
orrhea,  oxygen,  good  food  and  osteopathic  treatments  are  all 
that  are  necessary  in  ordinary  cases,  which  have  not  reached  the 
incurable  stage.  The  bowels  should  be  regulated,  and  the  other 
emunctories  put  in  working  order.  Plenty  of  good  water  should 
be  advised,  since  the  body  is  composed  so  largely  of  water.  Most 
people  drink  too  little  water,  which  is  the  cause  of  many  kidney 
troubles  as  well  as  constipation. 

The  treatment  to  start  menstruation,  when  suddenly  stopped 
by  exposure,  should  be  applied  to  the  lower  lumbar  and  sacral 
regions.  The  uterus  is  contracted  and  by  deep  work  over  these 
regions  its  muscle  fibers  can  be  relaxed.  In  such  cases  bony 
lesions  are  not  alwa^'s  found  at  first,  but  often  occur  later,  on 
account  of  the  constant  tension  exerted  by  the  contractured 
muscles.  In  acute  cases,  muscular  lesions  are  the  most  common, 
while  in  chronic  cases  the  bony  lesions  are  the  cause.  By  re- 
moving the  muscular  lesions  which  have  resulted  from  exposure, 
the  uterus  will  relax  and  the  flow  start  again  unless  it  has  been 
stopped  for  several  days.  The  muscles  are  relaxed  by  removing 
the  irritating  factors,  and  by  pressure  over  the  muscle  itself. 

SCANTY  MENSTRUATION  is  a  relative  term  used  to  indi- 
cate that  the  amount  of  menstrual  flow  has  become  less  than 
that  to  which  the  individual  has  been  accustomed.  In  some, 
the  flow  is  naturally  scant,  there  being  only  enough  to  stain  the 
cloth.  In  such  cases  it  is  not  pathological.  But  if  the  patient 
has,  at  her  previous  periods,  passed  the  normal  amount,  and 
afterwards  it  became  diminished,  it  is  pathological  and  needs 
treatment.  If  the  condition  is  the  result  of  impoverished  blood 
the  symptoms  will  be  few  or  absent.  If  due  to  uterine  displace- 
ment or  contraction,  the  patient  will  suffer  pelvic  pains,  weight 
in  the  pelvis,  backache  or  pains  in  the  joints  of  the  lower  limbs. 


GENERAL    DISORDERS    OF    MENSTRUATION.  409 

A  general  disturbance  of  circulation  follows,  as  is  evidenced  by 
the  COLD  HANDS  AND  FEET.  Uterine  forms  of  headache  and  sense 
of  tightness  in  the  head  follow.  This  is  confined  to  the  top  of 
the  head  or  the  suboccipital  region. 

The  causes  are  the  same  as  for  acquired  amenorrhea,  which 
has  been  considered.  Amenorrhea  frequently  commences  in 
the  form  of  scanty  menstruation.  Since  the  causes  are  very 
similar  to  those  producing  amenorrhea,  the  treatment  will  neces- 
sarily be  very  similar.  Increase  the  amount  of  blood  and  im- 
prove its  quality,  as  anemia  is  the  principal  condition  which  needs 
correction.  After  this  has  been  accomplished  treatment  should 
be  directed  to  the  pelvic  organs  to  better  their  blood  supply. 
This  is  done  by  correcting  lesions,  both  bony  and  muscular,  that 
obstruct  or  impair  the  blood  vessels  supplying  the  uterus.  If  the 
uterus  is  in  a  state  of  contraction,  such  as  is  fountl  in  superin- 
volution,  the  menses  are  lessened  in  amount  or  are  entirely  al5- 
sent.  In  such  cases  relax  the  uterine  muscle  fibers  by  an  inhibi- 
tory treatment  over  the  clitoris  and  the  sacral  region.  If  there 
is  a  tendency  to  scanty  menstruation  or  amenorrhea  a  strong 
treatment  during  the  menstrual  period  should  be  avoided.  I 
have  known  cases  of  amenorrhea  and  retarded  menstruation  to 
start  from  a  hard  stimulating  treatment  given  during  the  flow. 
For  this  and  several  other  reasons,  the  physician  should  know 
whether  or  not  the  patient  is  in  her  monthly  period  when  he  is 
treating  her  if  a  spinal  treatment  is  necessary. 

MENORRHAGIA  is  a  condition  in  which  the  menstrual  flow 
occurs  too  often  or  becomes  too  profuse.  The  increased  loss 
may  be  due  to  a  shortening  of  the  intermenstrual  period,  this 
being  the  result  of  a  prolonged  flow;  too  frequent  menstruation, 
such  as  occurs  every  two  weeks;  or  to  an  increa.sed  amount  at 
each  menstrual  period.     Menorrhagia  is  a  term  often  confound- 


410  DISEASES    OF    WOMEN. 

ed  with  metrorrhagia,  which  means  non-menstrual  uterine  hem- 
orrhage. 

It  is  a  common  complaint  and  gives  a  great  deal  of  alarm 
to  the  patient  besides  weakening  her  by  excessive  loss  of  blood. 
It,  like  scanty  menstruation,  Ls  a  relative  term,  since  what  would 
be  MENORRHAGIA  FOR  ONE  would  be  NORMAL  for  another.  How- 
ever, if  the  flow  suddenly  becomes  more  profuse  than  that  to 
which  the  patient  has  been  accustomed,  or  if  the  amount  lost  is 
clearly  enough  to  keep  the  woman  in  a  weakened  condition  and 
is  a  drain  upon  the  system,  from  which  she  does  not  recover  dur- 
ing the  intermenstrual  period,  it  is  regarded  as  Menorrhagia. 

CAUSES.  Menorrhagia  is  caused  by:  first,  a  relaxed  con- 
dition of  the  uterus;  second,  a  congested  condition  of  the  uterus; 
or,  THIRD,  it  is  due  to  some  disease  or  condition  which  lessens  the 
coagulability  of  the  blood. 

Bony  lesions  tend  to  affect  the  tonicity  of  the  uterus  by  shut- 
ting off  part  of  the  nerve  force.  This  causes  the  uterine  muscle 
fibers  to  relax  and  the  uterus  to  be  filled  with  blood,  hence  the 
menorrhagia.  This  is  one  of  the  important  causes,  and  the  one 
for  Avhich  the  osteopath  should  at  first  look.  Although  the 
uterus  is  diseased  or  displaced,  if  contraction  takes  place  hem- 
orrhage WILL  CEASE,  unless  the  blood  is  in  such  a  condition  that 
it  fails  to  coagulate.  As  mentioned  above,  the  middle  muscular 
layer  of  the  uterus  is  arranged  like  the  figure  eight,  encircling  and 
twining  around  and  among  the  blood  vessels.  If  these  fibers 
ARE  relaxed  the  blood  vessels  dilate  and  bleed  freely;  if  con- 
tracted they  act  as  ligatures  which  surround  the  vessels  and  pre- 
vent the  escape  of  the  blood.  This  is  accomplished  partly  by 
the  pressure  of  the  contracting  muscle  fibers,  and  partly  by  the 
formation  of  an  internal  clot. 

The  MOST  COMMON  BONY  lesion  that  I  have  found  is  a  back- 


GENERAL    DISORDERS    OF    MENSTRUATION.  411 

ward  twist  of  one  innominate  bone.  The  writer  has  treated 
cases  of  menorrhagia  caused  by  lesion  of  one  or  both  of  these 
bones  resulting  from  an  improperly  applied  treatment  given  by  a 
student,  or  even  a  physician,  whereby  the  innominates  were 
spread  apart,  or  otherwise  partially  tlislocated,  resulting  in  a 
marked  menorrhagia.  In  one  case  the  patient  was  placed  in  the 
dorsal  posture,  each  ilium  was  grasped  and  then  forcibly  separated, 
thus  producing  a  lesion  of  one  or  both  innominates.  Judging 
by  this  and  a  great  many  similar  cases,  there  is  no  doubt  but 
that  innominate  lesions  do  produce  menorrhagia. 

The  other  lesions  are;  a  tilted  sacrum,  spinal  lesions,  usually 
a  slight  curvature,  and  a  twisting  of  the  entire  pelvis.  The  back- 
ward slip  of  one  innominate  is  detected  by  a  change  in  the  direc- 
tion and  height  of  the  crests,  and  an  unnatural  prominence  of  the 
posterior  superior  spine  on  the  affected  side.  Tenderness  will 
be  found  at  its  articulation  and  over  the  upper  part  of  the  course 
of  the  sciatic  nerve.  This  tenderness  in  the  sciatic  nerve  is  in- 
dicative of  pelvic  congestion  and  is  a  common  symptom  in  men- 
orrhagia. The  length  of  the  limb  may  not  be  affected.  If  a  simple 
backward  rotation  is  found  the  limb  is  shortened,  but  very  often 
this  rotation  is  complicated  by  a  downward  slip  of  the  innomi- 
nate, hence  the  limb  may  be  lengthened,  shortened  or  not  altered 
in  length.  The  rule  is,  that  if  the  limb  is  slightly  lengthened 
and  of  RECENT  date,  it  indicates  hip  trouble;  if  shortened,  a 
slipped  innominate,  the  most  common  being  a  backward  rotation. 
These  lesions  cause  not  only  a  relaxation  of  the  uterine  muscle 
fibers,  but  also  of  the  muscle  fibers  of  the  walls  of  the  blood  ves- 
sels. This  produces  a  distention  and  congestion  and  is  a  gen- 
eral cause  of  menorrhagia.  Metritis  and  endometritis  are  pre- 
ceded and  accompanied  by  congestion.  In  fact,  all  inflammatory 
conditions  are  preceded  by  a  congestion.     The  extra  amount  of 


412  DISEASES    OF    WOMEN. 

blood  escapes  at  the  menstrual  period,  this  being  the  safety  valve 
by  which  the  congestion  is  relieved. 

A  SUBINVOLUTED  uterus  is  FULL  OF  BLOOD,  enlarged,  and  is 
sometimes  the  seat  of  inflammation  and  the  cause  of  menorrhagia. 
Laceration  prevents  contraction  of  the  uterus,  hence  the  congest- 
ed condition.  A  granular  erosion  keeps  the  parts  congested, 
causing  a  tendency  to  profuse  menstruation.  Since  unhealed 
laceration  of  the  cervix  uteri  is  the  most  common  cause  of  erosion, 
it  should  be  looked  to  as  the  primary  cause  of  congestion,  hence 
the  menorrhagia  in  such  cases.  Often  there  is  eversion  or 
ECTROPiUM,  endometritis,  granulations  or  sensitive  papillae  which 
bleed  freely  on  irritation. 

These  uterine  inflammations  also  excite  glandular  se- 
cretions, which  form  a  large  part  of  the  discharge.  Inflamma- 
tion of  the  mucous  surfaces  at  first  diminishes  the  normal  secre- 
tions, which  afterwards  become  abnormal  in  quality  and  increased 
in  amount.  This  weakens  the  system  almost  as  much  as  the 
loss  of  blood. 

Extra-uterine  inflammation  affecting  the  ovaries,  or 
oophoritis  and  salpingitis  lead  to  pelvic  congestion  and  an  in- 
creased flow.  If  the  inflammation  impairs  the  function  of  the 
ovaries  to  any  great  extent  there  is  a  tendency  to  amenorrhea. 

Uterine  displacements  cause  congestion,  resulting  in  men- 
orrhagia if  the  congestion  is  marked.  The  most  prevalent  form 
of  displacement  producing  menorrhagia  is  retroversion,  al- 
though it  may  follow  any  form  if  there  is  much  congestion.  Fi- 
broid tumors  cause  menorrhagia,  the  degree  depending  upon  the 
location  of  the  tumor  with  reference  to  the  uterine  wall.  A  sub- 
peritoneal fibroid  causes  the  mildest  form,  the  submucous  varie- 
ty the  most  profuse.  Polypi  or  other  fungosities  in  the  uterus 
almost    invariably   produce    menorrhagia.     The   profuseness   of 


GENERAL    DISORDERS    OF    MENSTRUATION.  413 

the  flow  is  by  no  means  in  proportion  to  the  size  of  the  intra- 
uterine growth,  since  small  polypi  often  act  as  potently  as  large 
tumors.  The  menorrhagia  is  in  such  cases  determined  by  the 
amount  of  congestion  of  the  mucous  membrane.  About  the 
first  symptom  of  the  presence  of  a  fibroid  tumor  or  a  fungosity 
is  menorrhagia;  this  is  due  to  the  congestion  which  accompanies 
the  tumor.  The  hemorrhage  does  not  at  first  come  from  the 
tumor  itself  but  from  the  congested  endometrium.  This  is  also 
true  of  malignant  tumors  appearing  before  the  menopause.  In 
such  cases  the  hemorrhage  is  bright  in  color  and  comes  in  gushes. 
The  arteries  are  eroded  by  the  progress  of  the  disease  and,  since 
the  parts  are  more  congested  at  the  menstrual  period  than  at 
other  times,  the  hemorrhage  is  more  marked  at  that  time. 
This  often  results  in  an  irregular  uterine  hemorrhage  called 
metrorrhagia. 

Foreign  bodies  such  as  retained  pessaries,  sponges  and  tents 
set  up  a  congestion  which  is  frequently  followed  by  a  profuse 
menstruation.  This  is  also  found  in  an  incomplete  abortion,  or 
retention  of  secundines  after  normal  labor,  but  in  such  cases  the 
hemorrhage  is  rather  of  the  form  of  a  metrorrhagia.  Organic 
heart  disease  produces  a  passive  congestion  of  the  uterus.  This 
is  sometimes  followed  by  a  profuse  menstruation,  but  this  does 
not  necessarily  follow. 

Enteroptcsis,  or  an}-  obstruction  which  produces  a  passive 
congestion  will  also  produce  menorrhagia,  so  that  the  causes 
given  under  congestion  of  the  uterus  may  be  regarded  as  causes  of 
profuse  menstruation.  The  first  two  causes  mentioned  are  usually 
associated.  A  congested  uterus  implies  one  in  which  the  walls 
are  relaxed. 

Excitement,  over-exertion,  exposure  or  a  hard  spinal  treat- 
ment at, or  just  prior  to,  the  period,  often  produces  a  marked  in- 
crease in  the  amount  of  the  discharge. 


414  DISEASES    OF    WOMEN. 

Membranous  dysmenorrhea  is  accompanied  by  flooding. 
This  occurs  at  the  time  of,  or  immediately  after  expulsion  of  the 
membrane,  and  lasts  from  a  few  hours  to  a  day  or  more.  It 
weakens  the  patient  to  a  marked  extent,  as  arterial  blood  is  lost 
in  abundance. 

The  third  cause  mentioned  is  that  of  some  blood  disease  in 
which  its  coagulability  is  affected.  Any  debilitating  disease  in 
its  early  stages,  on  account  of  the  thin  condition  of  the  blood, 
may  produce  menorrhagia,  before  the  onset  of  amenorrhea, 
which  occurs  after  the  disease  has  become  chronic  and  the  quantity 
of  blood  lessened.  A  debilitated  condition  of  the  whole  system  is 
usually  accompanied  by  amenorrhea,  but  occasionally  the  op- 
posite is  true.  These  causes  are  frequently  found  in  young  girls 
who,  at  the  age  of  puberty,  have  grown  rapidly,  developed  too 
early,  or  suffer  from  anemia  or  some  other  weakening  disease  in 
which  the  coagulability  of  the  blood  is  affected.  Menstrua- 
tion comes  on  irregularly  or  too  frequently,  occurring  every 
second  or  third  week.  Sexual  excitement,  just  prior  to  puber- 
ty, often  deranges  the  menses,  producing  copious  menstruation, 
probably  on  account  of  the  increased  activity  of  the  ovaries. 
Excessive  venery  frequently  provokes  ovarian  and  uterine  con- 
gestion which,  after  a  while,  become  pathological  and  are  follow- 
ed by  menorrhagia.  During  lactation  the  menses  sometimes 
become  too  free  if  there  is  an  excessive  drain  of  milk,  or  if  coitus 
is  begun  too  soon  after  parturition.  In  the  early  stages  of  phthi- 
sis the  menses  are  usually  profuse,  but  afterwards  diminish  as 
the  disease  progresses. 

SYMPTOMS.  Menorrhagia  may  occur  in  three  forms:  first, 
a  shortening  of  the  intermenstrual  period,  that  is,  the  flow  is  pro- 
longed more  than  six  days;  second,  an  excessive  amount  of  the 
flow  at  the  period;  and  third,  menstruation  occurring  every  two 
or  three  weeks. 


GENERAL   DISORDERS   OF   MENSTRUATION.  415 

The  local  symptoms  would  be  a  too  profuse,  frequent  or  pro- 
longed flow.  The  COLOR  of  the  discharge  is  usually  of  a  brighter 
red  than  normal,  indicating  an  admixture  of  arterial  blood,  or  it 
may  be  venous  in  character  and  intermingled  with  mucous  se- 
cretions. If  the  loss  of  blood  is  very  great  it  produces  anemia, 
pallor  of  the  lips  and  ears,  and  a  rapid  weak  pulse  which  is 
easily  excited.  There  may  be  weakness,  faintness,  a  clammy 
skin,  backache  and  a  general  neurasthenic  condition.  If  a  pa- 
tient is  anemic,  weak  and  tires  readily  on  the  least  exertion  it 
indicates  a  lack  of  good  blood.  This  may  arise  from  the  loss  of 
blood  in  menorrhagia,  or  it  may  be  due  to  a  lack  of  blood  for- 
mation and  as  a  consequence  in  such  cases  amenorrhea,  instead 
of  menorrhagia  is  the  menstrual  disturbance.  The  color  of  the 
blood  should  be  noticed;  arterial  hemorrhage  from  any  part 
OF  the  body  at  any  time  being  abnormal.  Such  hemorrhages 
very  rapidly  weaken  the  patient.  If  the  discharge  is  venous  in 
character  it  is  not  so  alarming. 

DIAGNOSIS.  Sometimes  it  is  very  hard  to  tell  whether 
the  hemorrhage  is  the  result  of  menstruation  or  comes  from  a 
tumor,  or  some  other  condition  such  as  an  abortion,  which  might 
cause  an  irregular  discharge  of  blood.  ,  If  the  flow  is  simply  an 
increase  in  amount  of  the  menses  the  molimina  will  be  pres- 
ent and  the  flow  be  very  near  the  normal  as  to  color  and  odor. 
If  the  result  of  an  abortion,  the  diagnosis  is  based  on  the  con- 
dition of  the  mammary  glands,  there  being  present  the  early 
mammary  signs  of  pregnancy  also  the  secretion  of  milk  coupled 
with  enlargement  of  the  breasts,  expulsion  of  the  embryo  or  fetus 
with  its  membranes,  no  history  of  previous  attacks,  and  the 
change  through  which  the  flow  passes,  it  becoming  lighter  from 
day  to  day  untU  it  is  watery  in  appearance  b}^  the  time  it  ceases. 
The  other  early  signs  and  symptoms  of  pregnancy  can  be  ascer- 
tained in  some  cases,  this  assisting  the  diagnosis. 


416  DISEASES    OF    WOMEN. 

If  the  hemorrhage  is  due  to  fibroid  tumor  or  cancer,  the  his- 
tory of  the  case,  the  presence  of  the  tumor,  in  short,  the  diagnostic 
indications  of  the  enlargement  are  present,  therefore  the  diag- 
nosis is  based  on  locating  the  enlargement  and  noting  its  char- 
acter. 

The  hemorrhage  may  be  so  irregular  that  the  patient  cannot 
tell  which  is  the  normal  time.  If  it  is  the  menstrual  time,  other 
symptoms  of  menstruation  will  be  present,  such  as  tenderness  in 
the  breast,  increased  pallor  of  the  complexion,  herpes,  a  more 
severe  headache  and  backache  and  a  general  weakness. 

Before  deciding  that  the  case  is  one  of  profuse  menstruation 
ascertain  the  normal  amount  for  that  individual  and  note  the 
secondary  anemic  symptoms.  If  the  loss  of  blood,  even  though 
IT  BE  GREAT,  causes  uoue  of  the  reflex  symptoms  mentioned, 
it  is  not  pathological  and  does  not  need  treatment.  If  molimina 
accompany  the  discharge  of  blood,  it  is  a  Menorrhagia  if  the 
amount  is  excessive. 

TREATMENT.  The  treatment  should  be  applied  to  the 
cause  of  the  trouble,  since  menorrhagia  is  only  a  symptom.  The 
first  thing  to  do  in  marked  cases  is  to  place  the  patient  in  bed 
with  the  feet  higher  than  the  head  and  keep  her  quiet,  both 
physically  and  mentally.  Make  the  environment  as  cheer- 
ful and  quiet  as  possible;  do  not  allow  visitors;  relieve  the  patient 
of  any  anxiety,  for  worry  and  excitement  make  the  condition 
much  harder  to  cure;  keep  her  in  bed,  or  at  least  off  her  feet,  so 
long  as  the  hemorrhage  continues,  for  the  erect  posture,  and  es- 
pecially walking  tends  to  congest  the  uterus. 

Those  cases  due  to  the  first  mentioned  cause,  a  relaxed  con- 
dition of  the  uterus,  can  be  cured  by  producing  contraction  of 
the  uterus,  this  being  accomplished  by  correcting  the  lesions 
which  prevent  contraction.     If  the  nerves    going  to  the  uterus 


GENERAL    DISORDERS    OF    MENSTRUATION.  417 

can  be  stimulated  the  uterus  will  certainly  contract.  Bony 
as  well  as  muscular  lesions  inhibit  the  nerves  going  to  the  uterus, 
hence  their  contraction  would  result  in  a  stimulation  of  all  those 
nerves.  Contraction  can  be  temporarily  accomplished  by  strong 
manipulation  over  the  lumbar  and  sacral  regions,  by  deep  cir- 
cular massage  over  the  uterus,  or  by  producing  a  sudden  shock 
or  stimulation  by  the  application  of  something  hot  or  cold  to  the 
abdomen.  A  slap  on  the  abdomen  with  the  cold  hand,  or  a  quick 
jerk  of  the  hair  on  the  mons  Veneris  is  resorted  to  in  cases  of  pro- 
fuse hemorrhage  in  which  an  immediate  contraction  of  the  uterus 
is  wanted.  Sometimes  a  sudden,  but  thorough  spanking  of  the 
buttocks  is  the  best  treatment  that  can  be  given  to  get  a  quick 
result.  The  shock,  it  being  unexpected  by  the  patient,  produces 
a  contraction  of  the  uterus,  that  will  stop  any  hemorrhage  if  the 
contraction  is  great  enough  to  ligate  the  blood  vessels.  It  may 
not  always  be  policy  to  give  such  a  treatment,  but  necessity  may 
demand  it.  This  causes  retraction  as  well  as  contraction  of  the 
uterus. 

Abortions  can  sometimes  be  stopped  in  a  similar  way,  this 
causing  contraction  of  the  cervix.  If  the  uterus  can  not  be  made 
to  contract  by  the  above  treatment,  resort  is  made  to  tampon- 
ing the  vagina.  This  often  causes  a  clot  to  form,  after  which 
the  hemorrhage  ceases.  The  best  tampon  to  use  is  the  chain 
tampon,  that  is  several  small  tampons  tied  together,  enough 
being  used  to  completely  fill  the  vagina  if  hemorrhage  is 
marked.  If  some  astringent,  such  as  witch  hazel  is  used  there 
will  be  a  quicker  effect.  This  particular  astringent  I  believe  is 
best  since  it  is  soothing  and  healing,  and  is  especially  good  if  in- 
flammation is  present.  Some  advise  the  use  of  alum,  others 
taimin.  Such  treatments  are  only  palliative.  They  do  not 
remove  the  cause  of  the  trouble,  hence  do  not  cure.     Local  va- 


418  DISEASES    OF    WOMEN. 

ginal  treatments  are  indicated  in  some  cases,  particularly  in  those 
due  to  trauma  resulting  in  uterine  displacement.  More  than 
usual  care  should  be  exercised  in  giving  a  local  treatment  while 
the  menses  are  on,  as  infection  or  inflammation  may  follow. 

In  cases  of  fungosities  of  the  uterus,  surgeons  advise  the  use 
of  the  sharp  uterine  curette.  The  polypi  are  thus  removed  and 
occasionally  the  patient  is  benefited.  The  osteopath  is  seldom 
warranted  in  using  such  radical  measures;  relying  for  a  cure  on 
removal  of  the  cause  of  the  disturbance.  The  polypus,  if  pro- 
truding beyond  the  external  os,  can  and  ought  to  be  removed. 

In  PARTIAL  INVERSION  of  the  uterus,  the  indentation  should 
be  removed  by  use  of  a  large  blunt  sound.  Such  cases  occur  in 
patients  recovering  from  parturition,  in  the  very  weak  and 
atonic,  and  often  at  the  menopause. 

In  FIBROID  TUMORS  in  which  the  menorrhagia  is  marked, 
little  can  be  done  until  the  growth  of  the  tumor  is  checked,  which 
often  takes  several  months.  In  the  meantime  resort  is  made  to 
rest  in  bed  and,  in  bad  cases,  the  use  of  some  astringent. 

If  the  menorrhagia  is  the  result  of  congestion  and  inflamma- 
tion of  the  uterus,  it  should  be  treated  as  outlined  under  the 
head  of  metritis  and  endometritis.  If  the  quality  of  the  blood 
is  impaired  treatment  should  be  directed  to  the  blood  forming 
organs.  Anything  which  improves  the  general  health  is  bene- 
ficial in  the  treatment  of  this  form  of  menorrhagia.  For  per- 
manent RELIEF  and  CURE,  REMOVE  THE  LESIONS,  correct  the 
DISPLACEMENTS  of  the  uterus  and  build  up  the  quality  of  the 

BLOOD. 

DYSMENORRHEA  is  a  term  used  to  denote  pain,  preceding, 
accompanying  or  following  the  menstrual  discharge,  and  which 
is  dependent  on  a  disturbance  of  the  menstrual  function.  This 
includes  pain  referred  to  the  pelvic  organs  which  occurs  at  any 


GENERAL   DISORDERS   OF   MENSTRUATION.  419 

time  during  the  menstrual  process,  dating  from  the  rupture  of 
the  Graafian  follicle  and  ending  with  the  completion  of  the  dis- 
charge. This,  like  the  other  menstrual  disorders,  is  only  symp- 
tomatic, indicating  some  disease  or  abnormality  of  the  organs 
which  take  part  in  the  menstrual  process. 

It   is   the    MOST    COMMON   of   ALL   THE    MENSTRUAL    DISORDERS 

and  one  that  almost  ever}'  woman  experiences  either  in  the  chronic 
or  acute  form.  In  fact,  pain  at  the  sick  time  is  so  common  that 
it  is  regarded  by  most  women  as  a  necessary  accompaniment 
of  menstruation.  Theoretically  normal  menstruation  is  pain- 
less, free  from  clots  and  causes  little  inconvenience. 

Dysmenorrhea  varies  in  degree  from  a  few  pains,  which 
do  not  interfere  with  the  patient's  occupation,  to  a  complete 
prostration  which  keeps  her  in  bed  for  some  days.  In  some 
cases  one  attack  is  scarcely  over  before  another  is  ready  to  com- 
mence. Some  women  are  more  sensitive  to  pain  than  others 
and  exaggerate  the  pain  felt,  thus  making  it  hard  to  estimate  the 
amount  of  real  pain  from  the  description  given  by  the  patient. 

PAIN  is  a  sensation  which  is  distressing  or  agonizing.  It 
is  the  result  of  irritation  of  a  sensory  nerve  or  nerves  and  the  con- 
veyance of  the  impulse  to  the  sensorium.  which  refers  it  back  to 
the  periphery  of  the  sensory  nerve  involved.  In  this  way  it  is 
possible  for  the  pain  to  be  referred  to  a  part  not  diseased,  if  con- 
nected with  the  nerve  stimulated,  in  which  it  Ls  a  case  of  mistaken 
identity  on  the  part  of  the  sensorium.  Pain  is,  in  reality,  in  the 
sensorium.  All  pains  are  referred  to  their  supposed  sources, 
that  is,  to  the  point  at  which  the  stimulus  is  supposed  to  be. 
In  cases  of  visceral  irritation  or  disease  the  impulses  generated 
are  carried  to  the  spinal  cord,  thence  up  the  posterior  columns 
to  the  .sensorium.  and  on  account  of  the  low  degree  of  sensi- 
bility of  the  viscera,  the  pain  is  referred  to  the  cerebro-spinal 


420  DISEASES    OF    WOMEN. 

nerves  in  close  central  connection.  This  seems  to  be  a  wise  pro- 
vision on  the  part  of  nature  for  the  purpose  of  protection, 

the  BODY  BEING  GUARDED  BY  SENSORY  NERVES  which  act  aS  "LIVE 

WIRES,"  thus  warning  the  organism  of  a  threatened  or  real  dan- 
ger. Head's  law  which  offers  a  very  good  explanation  of  referred 
pain  is  as  follows:  "When  a  painful  stimulus  is  applied  to  a  part 
of  low  sensibility  in  close  central  connection  with  an  area  of  much 
greater  sensibility,  the  pain  produced  is  felt  in  the  part  of  higher 
sensibility  rather  than  in  the  part  to  which  the  stimulus  was  ap- 
plied, unless  the  stimulus  is  very  great  or  long  continued."  To 
be  more  explicit  or  rather  to  apply  it  to  dysmenorrhea,  a  pain- 
ful stimulus  applied  to  the  uterus  will  cause  pain  in  the  abdominal 

wall  OVER  THE  UTERUS. 

This  SENSORY  IRRITATION  is,  in  most  cases  of  dysmenorrhea, 
the  result  of  pressure.     The  pressure  may  be  of  various  kinds, 

but  BLOOD  PRESSURE  and  PRESSURE  FROM  MUSCULAR  CONTRAC- 
TION, are  the  most  common.  This  disturbs  the  nutrition  of  the 
nerve  or  even  affects  the  nerve  substance  itself.  The  degree  of 
pain  depends  upon  the  degree  of  pressure  and  starvation  of  the 
nerve.  In  one  case  there  is  sharp  pain,  in  another  a  dull,  radia- 
ting or  labor-like  pain,  and  may  be  constant  or  intermittent.  It 
may  become  intense  just  before,  or  just  after  the  flow  begins,  or 
it  may  continue  while  the  flow  is  on.  The  seat  of  the  pain  may 
be  in  the  ovary,  peritoneum,  tubes  or  uterus,  but  it  may  be  re- 
ferred to  the  back,  side,  abdomen  or  limbs. 

VARIETIES  of  dysmenorrhea  depend  upon  the  organs  in- 
volved and  how  they  are  affected.  It  is  usually  divided  into  three 
types:  First,  the  ovarian  type,  in  which  the  pain  precedes  the 
flow  and  is  referred  to  the  ovary;  second,  the  obstructive  type; 
and  third,  the  inflammatory.  Usually  these  types  are  not  dis- 
tinct but  are  combined,  one  running  into  the  other.     The  ob- 


GENERAL   DISORDERS  OF   MENSTRUATION.  421 

structive   and  inflammatory  forms  most  commonly  go  together. 

From  the  history  of  the  case,  the  variety  can  be  ascertained. 
If  the  pain  precedes  the  flow  from  four  to  eight  days  it  belongs  to 
the  OVARIAN  type;  if  it  immediately  precedes  the  flow  and  is  re- 
lieved by  the  starting  of  the  flow,  it  is  the  obstructive  form  and 
probably  due  to  a  flexion.  If  the  pain  continues  throughout  the 
period,  it  is  due  to  inflammation;  if  it  precedes  and  also  accom- 
panies the  flow  it  belongs  to  both  the  obstructive  and  inflamma- 
tory type,  such  as  is  found  in  flexion  accompanied  by  an  endo- 
metritis. 

CAUSES.  At  each  menstrual  period  the  pelvic  organs 
BECOME  CONGESTED.  Any  diseased  condition  of  these  organs 
tends  to  increase  the  congestion,  and  if  the  inflammatory  stage 
is  reached,  painful  menstruation  follows.  The  ovaries  share  in 
this  congestion  or  they  may  be  separately  diseased.  It  is  con- 
ceded by  most  writers  that  the  ovaries  congest,  the  Graafian  fol- 
licles swell  and  rupture  and  that  the  ovum  escapes  a  few  days 
prior  to  the  beginning  of  the  menstrual  flow.  If  this  process  is 
hindered  or  impaired  it  is  liable  to  terminate  in  pain.  In  some 
cases,  the  rupture  of  a  follicle  is  hindered  by  the  toughness  of 
the  tunic  or  covering  of  the  ovary.  Inflammation  of  the  ovary, 
called  ovaritis,  causes  pain  on  account  of  the  markedly  increased 
congestion  at  that  time.  The  congestion  increases  the  pressure, 
hence  the  pain.  As  soon  as  the  follicle  ruptures  the  congestion 
is  relieved  and  the  pressure  decreased. 

Lesions  in  the  lower  dorsal  region  affect  the  ovary  and  pro- 
duce pathological  congestion.  In  chronic  cases,  these  lesions  are 
bony,  but  in  acute  cases  usually  muscular.  A  case  in  point 
might  be  cited.  A  young  woman,  aged  sixteen,  was  taken  with 
a  severe  pain  in  the  side  and  back  about  three  days  prior  to  the 
time  at  which  the  flow  was  expected  to  begin.     On  examination 


422  DISEASES    OF    WOMEN. 

the  muscles  over  the  lower  dorsal  region  were  very  much  con- 
tractured.  By  relaxing  these  muscles  the  pain  was  stopped 
within  a  short  time.  This  is  the  cause  of  ovarian  colic  or 
"cramps"  which  is  so  common.  As  mentioned  before,  always 
look  for  muscular  lesions  in  acute,  and  bony  lesions  in  chronic 
cases. 

Inflammatory  conditions  of  the  structures  around  the  ovaries 
also  impair  their  function  and  produce  this  form  of  dysmenor- 
rhea. Salpingitis  and  perimetritis  are  the  most  common  of  these 
inflammatory  conditions  around  the  ovary.  The  broad  liga- 
ments are  frequently  found  inflamed,  resulting  in  their  contrac- 
tion and  from  this  a  disturbance  of  the  ovary. 

The  obstructive  form  of  dysmenorrhea  is  the  type  attributed 
to  a  mechanical  obstruction  of  the  uterine  canal.  Although  this 
is  mentioned  by  some  writers  as  an  important  cause,  I  think  it 
is  not  so  important  as  some  other  causes,  especially  the  inflamma- 
tory conditions.  Since  the  blood  is  able  to  pass  through  even  a 
capillary,  there  must  be  a  very  marked  and  complete  obstruc- 
tion of  the  uterine  canal  to  prevent  the  exit  of  blood. 

Amputation  of  the  cervix,  trachelorraphy,  or  any  operation 
on  or  injury  of  the  cervix,  usually  results  in  the  formation  of 
cicatricial  tissue,  which  produces  dysmenorrhea.  In  such  cases  there 
is  an  obstruction  caused  by  the  scar  tissue  plus  an  interference 
with  the  expellant  power  of  the  uterus. 

The  obstructive  form  is  rarely  found  alone,  being  most  fre- 
quently associated  with  inflammation,  such  as  endometritis. 
The  flexions,  especially  anteflexion,  are  cited  as  the  most  typi- 
cal and  most  common  causes  of  obstructive  dysmenorrhea.  The 
uterine  walls  collapse  at  the  point  of  flexion,  which  condition 
not  only  obstructs  the  uterine  canal,  but  also  the  blood  ves- 
sels, so  that  when  the  menstrual  blood  passes  into  the  cavity 


GENERAL    DISORDERS  OF    MENSTRU ATIOX.  423 

of  the  uterus,  it  meets  with  this  obstacle  and  stops.  On  account 
of  this  retention  there  is  coagulation'  and  the  presence  of  the 
clots  excites  the  uterine  contractions  which  cause  the  pain.  The 
pain,  however,  will  be  insignificant  unless  there  is  a  co-existing 
inflammation.  This  form  is  most  commonly  found  in  the  young 
but  sometimes  occurs  in  multiparae.  Stenosis  of  the  os  may 
occur  from  other  causes,  such  as  cicatrization  resulting  from  in- 
flammation. If  this  occurs  at  the  internal  os,  it  very  readily 
impinges  on  the  cervical  canal  causing  a  narrowing  at  that  point. 
The  tissues  in  the  region  of  the  internal  os  may  thicken  and  be- 
come rigid. 

Erosion  of  the  cervix  is  productive  of  dysmenorrhea  since, 
in  most  cases,  papillae  form  around  the  os  and  become  very  sen- 
sitive, and  the  pressure  caused  by  the  menstrual  discharge  re- 
sults in  contraction  of  the  circular  muscle  fibers  in  the  cervix 
thus  closing  the  os  and  partly  or  completely  stopping  the  flow. 
A  very  slight  exciting  cause,  such  as  catching  cold,  overwork  or 
emotional  disturbances,  will  cause  contraction  of  the  cervix.  In 
such  cases  the  cervix,  on  digital  examination,  has  a  soft  velvety 
feeling,  although  in  some  cases  the  papillae  can  be  outlined.  On 
examination  with  a  speculum  the  tissues  around  the  external  os 
are  red  in  appearance. 

There  may  be  a  uterine  polypus  which  acts  like  a  ball 
valve,  thereby  preventing  the  exit  of  the  flow.  The  mucous 
membrane  becomes  congested  and  in  this  way  produces  a  nar- 
rowing of  the  canal.  The  circular  muscle  fibers  of  the  cervix 
are  often  found  contracted  as  a  result  of  the  irritation,  leading  to 
a  stenosis  of  the  os. 

Lesions  which  cause  a  stimulation  of  the  nerves  going  to 
these  parts  may  excite  uterine  contraction,  the  most  common 
lesions  being  those  affecting  the  pelvic  bones,  principally  the  in- 


424  DISEASES    OF    WOMEN. 

nominates.  Sudden  fright  or  shock  causes  contraction  of  this 
part  of  the  uterus  and  results  in  stopping  the  flow  and  clots  soon 
form  which  excite  pain  upon  their  expulsion.  If  the  entire  uterus 
relaxes  suddenly,  the  flow  will  be  brought  on,  this  being  the 
case  in  a  sudden  fright  or  excitement. 

The  condition  of  infantile  uterus  is  frequently  the  cause  of 
dysmennorrhea,  in  fact  painful  menstruation  is  found  in  every 
TYPICAL  case  of  infantile  uterus.  The  cervix  is  small,  elongated, 
softened  and  conical  and  the  canal  running  through  it  is  almost 
obliterated.  It  relaxes  with  difficulty  and  a  great  deal  of  pressure 
from  behind  is  necessary  to  force  anything  through  the  canal. 
The  pressure  is  produced  by  uterine  contraction,  and  uterine  con- 
traction, if  abnormally  hard,  is  always  attended  by  pain,  hence 
the  pain  in  this  form  of  dysmenorrhea. 

This  kind  of  dysmenorrhea  dates  from  puberty  as  a  rule, 
and  the  pain  is  confined  to  a  few  days  just  prior  to  the  menstrual 
flow,  the  patient  being  comparatively  well  during  the  inter- 
menstrual period. 

Faulty  development  is  back  of  nearly  all  of  the  obstructive 
types  of  dysmenorrhea  which  occur  in  nulliparae.  Even  normal 
congestion  preceding  and  accompanying  menstruation  is  attend- 
ed by  suffering,  since  there  is  a  lack  of  provision  for  normal 
expansion.  "The  organ  is  imperfect  and  unripe  and,  like  the 
nut  which  casts  its  hull  at  maturity,  it  clings  to  its  decidua  most 
tenaciously    before    that    period."     The    blood    vessels    seem 

SMALL  AND  INCAPABLE  OF  CONTAINING  THE  PROPER  AMOUNT  OF 
BLOOD    NECESSARY    TO    NORMAL     MENSTRUATION     without    marked 

increase  in  intravascular  pressure  even  to  the  painful  degree. 
The  unripe  endometrium  prevents  what  there  is  from  es- 
caping into  the  uterine  cavity,  causing  pressure  and  consequent 
pain.     Schultze  says:  "During  the  time  that  the  pains  of  dys- 


GENERAL    DISORDERS  OF    MENSTRUATION.  425 

menorrhea  are  most  violent,  pains  which  according  to  theory, 
depend  on  the  retention  of  blood  in  the  cavity  of  the  uterus,  the 
sound  may  be  passed  over  and  over  again  as  far  as  the  fundus 
without  a  single  drop  of  blood  following  its  removal,  indeed  with- 
out a  single  drop  of  blood  leaving  the  uterus  for  hours  or  even 
days  afterwards,  though  the  passage  is  thus  proved  to  be  free." 
The  writer  has  man}'  times  confirmed  the  above  statement,  thus 
proving  that  the  blood  is  in  the  uterine  wall,  at  least  not 
IN  THE  CAVITY.  Ill  such  cases  if  the  nerves  are  already  hyper- 
sensitive from  a  lesion,  spinal  cord  disease  or  any  other  cause, 
the  pain  is  the  more  marked  as  a  result  of  the  uterine  contrac- 
tions, the  uterus  going  into  hard  labor  in  its  efforts  to  expel  an 
imaginary  object. 

From  this  it  can  be  seen  how  marriage  and  maternity  cure 
dysmenorrhea  due  to  faulty  development.  Coitus  and  preg- 
nancy develop  the  uterus,  and  parturition  removes  all  obstruc- 
tions. In  case  of  infantile  uterus,  it  generally  requires  several 
years  of  married  life  to  develop  it  to  such  a  degree  that  impreg- 
nation is  possible,  hence  the  many  cases  of  sterility  for  several 
years  after  marriage.  After  parturition,  the  endometrium  be- 
comes normal,  that  is,  a  new  mucous  membrane  develops  which 
is  not  thickened,  hypersensitive  or  diseased  as  was  the  former. 

The  longer  congestion  continues  without  hemorrhage  taking 
place,  the  more  violent  and  distressing  the  tenesmus  becomes. 
The  starting  of  the  flow,  if  especially  free,  relieves  the  intravas- 
cular pressure  and  the  contractions  diminish.  In  other  types  of 
obstructive  dysmenorrhea,  that  is,  the  forms  in  which  the  men- 
strual flow  reaches  and  accumulates  in  the  uterine  cavity,  there 
is  some  disturbance  of  the  expellant  forces  of  the  uterus.  Either 
the  fundus  does  not  contract  hard  enough,  or  the  cervix  con- 
tracts too  much;  at  least  polarity  is  deranged.     Polarity  is  that 


426  DISEASES    OF    WOMEN. 

peculiarity  of  contraction  of  the  uterus,  occurring  in  labor  and 
menstruation,  in  which  the  fundus  and  cervix  act  in  opposite 
ways,  viz :  when  the  fundus  contracts  the  os  dilates. 

The  inflammatory  causes  are  the  most  common  and  im- 
portant. As  mentioned  above,  there  is  a  physiological  con- 
gestion of  all  the  pelvic  organs  at  the  menstrual  period  which 
should  disappear  after  menstruation.  If  there  is  a  weakness  or 
disease  the  congestion  does  not  entirely  disappear.  Displace- 
ments of  the  uterus,  lesions  along  the  lower  part  of  the  spine  and 
pelvic  bones,  lack  of  care  at  the  menstrual  period,  occupations 
in  which  the  patient  is  on  her  feet  a  great  deal,  and  mode  of  dress 
all  tend  to  increase  this  congestion,  which  leads  to  inflammation, 
in  the  form  of  a  metritis  or  endometritis.  Chronic  metritis  af- 
fects the  entire  uterine  wall.  The  muscle  fibers  are  then  affected, 
hence  the  uterine  contraction  is  necessarily  attended  by  pain. 
The  blood  forms  into  clots  and  the  canal  is  lessened,  both  of  which 
are  conducive  to  dysmenorrhea.  Congestion  precedes  and  ac- 
companies the  metritis,  the  uterus  is  enlarged  and  the  pressure 
upon  the  sensory  nerves  is  increased.  In  active  congestion 
-there  is  a  painful,  throbbing  sensation  at  each  beat  of  the  heart. 
This  is  the  result  of  increased  pressure  at  each  ventricular  con- 
traction. 

Endometritis  is  probably  one  of  the  most  common  of  uterine 
diseases.  It  is  rare  to  get  a  tumor,  displacement,  or  any  dis- 
ease or  abnormal  condition  Avithout  some  co-existing  inflamma- 
tion of  the  endometrium.  This  mucous  membrane  thickens 
and  inflames  more  at  the  menstrual  period  than  at  any  other 
time  as  a  result  of  the  general  pelvic  congestion.  This  favors 
hemorrhage  and  coagulation  of  the  blood.  When  uterine  con- 
tractions begin,  and  they  are  present  in  normal  menstruation, 
the  uterus  is  contracting  over  and  around  the  inflamed  surface. 


GENERAL   DISORDERS  OF   MENSTRUATION.  427 

It  is,  as  mentioned  before,  like  gripping  something  with  the  hand 
when  the  palm  is  inflamed  and  sore.  It  certainly  excites  pain. 
The  walls  of  the  uterine  cavity  are  tender,  congested  and  inflamed 
and  any  contraction  produces  pain.  Now,  if  there  is  any  ob- 
struction as  from  a  narrowing  of  the  internal  os,  flexion  or  con- 
traction of  the  cervix,  the  pain  is  increased  in  proportion  to  the 
degree  of  the  obstruction. 

There  is  a  form  of  painful  menstruation,  the  result  of  con- 
gestion and  inflammation  of  the  endometrium,  called  mem- 
branous dysmenorrhea.  It  consists  of  an  exfoliation  of  the  endo- 
metrium and  its  expulsion  en  masse  at  the  menstrual  period. 
See  Fig.  102.     A  stripping  off  and  expulsion  of    this  membrane 


Fig.  102. — A  dysmenorrhea!  membrane  laid  open.  (Coste.) 

through  a  small  opening  is  attended  by  intermittent  pains  very 
similar  to,  and  even  worse  than  those  of  labor.  This  is  a  severe 
and  chronic  form  of  dysmenorrhea  and  one  supposed  by  the  med- 
ical profession  to  be  the  hardest  type  of  menstrual   disorder  to 


428  DISEASES    OF    WOMEN. 

cure,  in  fact  it  is  regarded  as  incurable,  but  osteopathic  treat 
ment  seldom  fails  in  such  cases. 

Back  of  these  congestive  and  inflammatory  conditions, 
bony  lesions  are  sought  for  in  chronic  cases,  and  upon  their  cor 
rection  depends  the  cure.  Osteopathy  corrects  these;  that  is 
why  we  cure  when  other  methods  fail. 

Inflammation   of  the  structures   around   the   uterus   is   fro 
quently  found  as  a  cause  of  dysmenorrhea.     This  leads  to  ovarian 
inflammation  and  salpingitis,  and  each  menstrual  period  increases 
the  pain  on  account  of  the  extra  congestion  at  that  time.     Mal 
FORMATION,  such  as  atresia,  causes  retention  of  the  normal  flow 
and  finally  there  is  painful  distention  . 

Some  cases  are  due  to  constitutional  causes,  such  as  gout 
and  RHEUMATISM.  There  may  be  a  neurosis,  such  as  neuras- 
thenia or  hysteria,  which  makes  menstruation  painful.  Some 
writers  have  mentioned  a  neuralgic  type  of  dysmenorrhea.  This 
is  usually  found  in  nulliparae.  The  os  internum  is  in  a  state  of 
hyperesthesia,  which  may  be  due  to  a  fissured  or  inflamed  con- 
dition of  the  part  which,  like  anal  fissure,  causes  contraction. 
In  some  cases  there  is  a  cutaneous  hyperesthesia  of  a  neuralgic 
character  varying  in  time,  duration  and  intensity.  The  nasal 
type  of  dysmenorrhea  has  been  noted  by  the  author  in  a  few 
cases.  The  mucous  membrane  lining  the  nasal  fossa  is  hyper- 
sensitive. A  local  anesthetic  such  as  cocaine,  will  relieve  when 
applied  to  the  nose. 

Sudden  stoppage  of  the  flow  is  followed  by  pain  of  a  bearing 
down  character.  In  such  cases  there  is  a  contraction  of  the  cer- 
vix which  produces  a  stenosis  of  the  os.  This  is  called  the  spas- 
modic form  of  dysmenorrhea.  The  retained  blood  undergoes 
coagulation,  and  the  expulsion  of  the  clot  is  similar  to  the  ex- 
pulsion of  a  fetus.     In  such  cases  there  is  considerable  pain  at 


GENERAL  DISORDERS  OF  MENSTRUATION.  429 

the  NEXT  REGULAR  period.     Overwork  and  exposure  at  one 

MENSTRUAL     PERIOD     INVARIABLY      PRODUCE     AN     INTERFERENCE 

WITH  THE  NEXT.  Delayed  menstruation  causes  increased  con- 
gestion of  the  uterus,  absorption  of  some  of  the  menstrual  flow 
and  the  formation  of  clots,  this  causing  pain  when  the  menses 
finally  appear. 

SYMPTOMS.  The  symptoms  of  dysmenorrhea  are  pains, 
both  local  and  reflex,  of  every  possible  kind  as  to  time,  duration, 
severity  and  location.  The  pain  preceding  menstruation  is  call- 
ed ovarian  colic  or  cramp.  The  congestion  of  the  ovary  causes 
increased  pressure  on  the  nerve  terminals.  'The  patient  refers 
to  the  pain  as  in  the  stomach,  but  on  closer  inquiry  and  by  hav- 
ing her  place  her  hand  on  the  exact  spot  it  is  found  to  be  in  the 
ovary,  instead  of  in  the  stomach.  A  great  many  people  either 
do  not  know  where  the  stomach  is,  or  they  try  to  mislead  you  by 
telling  you  the  pain  is  in  the  stomach  when  in  reality  it  is  in  the 
pelvic  cavity  or  abdominal  wall  in  relation  with  the  uterus  or 
ovaries.  The  pain  may  be  referred  to  the  back,  lower  dorsal 
region,  or  the  side.  Be  careful  to  diagnose  ovarian  pain  from 
appendicitis,  renal  calculi,  biliary  colic,  and  from  a  dislocated  rib 
causing  pressure  on  an  intercostal  nerve. 

The  MUSCLES  over  the  ovary  and  lower  dorsal  region  will  be 
found  contractured.  If  the  pain  precedes  the  flow  and  is  re- 
lieved by  its  appearance,  it  is  of  the  obstructive  type.  The  pain 
is  usually  in  the  form  of  labor  pain,  that  is  intermittent  and  spas- 
modic, which  in  reality  it  is,  since  there  are  uterine  contractions. 
The  uterus  is  trying  to  overcome  an  obstruction  by  increased 
contraction.  In  neurotic  types  the  pains  increase  from  time  to 
time.  In  some  there  is  nausea  and  vomiting,  intense  headache 
and  neuralgic  pains  in  various  parts  of  the  body. 

The  other  pelvic  viscera  are  affected.     Often  there  is  a  limpid 


430  DISEASES    OF    WOMEN. 

condition  of  the  urine;  the  breasts  become  swollen  and  tender; 
there  is  an  achy,  dull,  heavy,  tired  feeling  in  the  lower  limbs  and 
back.  Nervous  prostration  follows  and  the  patient  is  confined 
to  her  bed  for  days  or  even  weeks.  The  muscles  of  the  back  and 
abdomen  are  tender,  in  short,  there  is  a  general  tenderness  over 
the  entire  abdomen  and  the  pain  persists  as  long  as  there  is  any 
discharge  to  be  expelled. 

DIAGNOSIS.  When  I  am  called  to  see  a  case  of  dysmenor- 
rhea I  usually  ask  first,  when  the  pain  commenced  with  refer- 
ence to  the  beginning  of  the  flow,  the  character  and  location  of 
the  pain,  what  caused  it  and  how  long  it  has  lasted.  If  the  pain 
precedes  the  flow  by  a  few  days  it  indicates  ovarian  trouble. 
Likewise  the  other  forms  may  be  partially  diagnosed  by  the  time 
of  appearance  of  the  pain.  In  this  way  I  am  able  to  judge  whether 
the  trouble  is  ovarian  or  uterine,  local  or  general,  acute  or  chronic, 
and  whether  it  is  due  to  muscular  or  bony  lesions,  a  displacement 
or  an  inflammatory  condition  of  the  uterus. 

Ovarian  colic  is  often  closely  simulated  by  a  displaced  rib 
OR  ribs;  in  fact,  this  displacement  often  produces  acute  ovarian 
colic,  hence  the  ribs  should  be  examined  very  carefully  for  any 
deviation  from  the  normal,  or  for  tender  spots.  In  biliary  cal- 
culi the  other  symptoms  are  present,  such  as  jaundice,  pain  high 
up  on  the  right  side,  constipation,  and  it  is  not  associated  with 
the  menstrual  period.  Renal  calculi  can  be  diagnosed  by  the 
location  of  the  pain,  it  following  the  course  of  the  ureter  and 
terminating  in  the  vulva  or  inside  the  limb,  urinary  disturbances, 
such  as  frequent  micturition,  hematuria,  lessening  of  the  amount 
of  secretion  of  urine,  and  tenderness  over  the  kidney  and  ureter 
on  the  affected  side.  The  membranous  form  of  dysmenorrhea 
is  diagnosed  from  abortion  by  placing  the  membranous  discharge 
in  clear  water.     After  the  blood  clots  have  been  washed  out,  no 


GENERAL  DISORDERS  OF  MENSTRUATION.  431 

embryo  can  be  found.  The  membrane  has  a  shredded  appear- 
ance and  floats  in  the  water.  Again,  in  membranous  dysmen- 
orrhea, there  are  absent  the  usual  signs  of  pregnancy  which  are 
found  in  pregnant  women  prior  to  the  second  month. 

In  diagnosing  the  different  forms  of  dA^smenorrhea  keep  in 
mind  which  factors  of  menstruation  are  involved.  If  the  ovaries 
are  diseased  their  function  is  altered  and  pathological  congestion 
results;  if  there  is  a  cystic  degeneration  ovulation  is  affected. 
If  the  uterus  is  inflamed  or  a  flexion  exists  the  expellant  forces 
of  the  uterus  are  involved.  Hence,  by  recalling  the  factors  neces- 
sary to  menstruation,  namely:  ovarian  congestion  (physiol- 
ogical) and  activity,  uterine  congestion  and  contraction, 
a  fluid  to  be  expelled  and  an  unobstructed  passageway,  the 
particular  cause  can  be  ascertained. 

TREATMENT.  The  treatment  of  dysmenorrhea  resolves 
itself  into  the  removal  of  the  cause  producing  it.  since  it,  like  the 
other  menstrual  disorders,  is  only  a  symptom  and  not  a  disease- 
If  of  the  ovarian  type,  correct  the  lesions  that  affect  the  ovarian 
center.  If  a  lower  rib  is  pressing  on  an  intercostal  nerve,  and 
this  is  a  very  common  cause,  correct  it  and  relax  the  muscles 
holding  it  in  malposition ;  the  quadratus  lumborum  being  the  one 
commonly  at  fault.  If  the  rib  or  vertebral  lesion  affects  the  cir- 
culation of  blood  to  and  from  the  ovarian  center,  a  correction  is 
imperative  if  a  cure  is  expected.  If  the  ovaries  are  drawn  down 
by  a  displaced  uterus,  correct  the  displacement.  In  ovarian 
colic  relax  the  contractured  muscles  over  the  lower  dorsal  region 
and  give  a  deep,  gentle  treatment  above,  around  and  over  the 
congested  ovary. 

By  drawing  up  the  intestines,  thus  releasing  the  obstruc- 
tions to  the  venous  return,  the  colic  or  neuralgia  can  be  relieved. 
If  a  chronic  case,  the  bony  lesions  must  be  corrected  or  the  above 


432  DISEASES    OF    WOMEN. 

treatments  will  give  only  temporary  relief.  In  conditions  of  ante- 
flexion of  the  uterus  producing  the  obstrucive  form,  work  deeply 
just  above  the  pubic  bone,  following  the  course  of  the  veins.  The 
uterus  may  be  straightened  by  placing  the  patient  in  the  dorsal 
position,  having  the  hips  elevated  if  possible,  and  giving  an  up- 
ward manipulation  over  the  uterus.  Nature  is  trying  to  straight- 
en the  canal  by  contraction,  and  sometimes  very  little  assistance 
is  sufficient  to  overcome  the  obstruction.  The  uterus  may 
straighten  of  its  own  accord,  but  it  takes  some  time  and  the  pro- 
cess is  very  painful.  A  local  treatment  should  not  be  resorted 
to  unless  the  efforts  to  correct  it  by  external  treatment  have 
failed;  then,  if  the  patient  is  suffering,  a  local  treatment  should 
be  given. 

Contraction  of  the  cervix  from  stimulation  of  its  nerve 
supply  can  be  relieved  by  a  treatment  applied  to  the  lower  dor- 
sal and  lumbar  regions  and  inhibition  over  the  clitoris.  The 
sacro-iliac  synchondrosis  is  the  most  effective  point.  I  have 
taken  cases  of  painful  contraction  of  the  uterus  in  which  there 
was  extreme  cramping  and  relieved  them  almost  immediately 
by  inhibiting  at  these  points.  The  inhibition  is  best  accom- 
plished by  correcting  the  slight  deviation  found  in  this 
joint.  Pressure  against  it,  with  some  rotation  of  the  innominate, 
relieves  or  releases  the  disturbed  nerve.  It  requires  about 
fifteen  minutes  to  relieve  the  cramps  in  an  ordinary  case.  The 
muscles  at  that  point  are  contracted  and  very  tender,  and  I  re- 
gard the  tender  spot  the  point  at  which  treatment  should  be 
given.  If  these  cramps  are  due  to  a  slight  delay  in  menstrua- 
tion a  strong  stimulating  treatment  in  the  lower  lumbar  region 
is  usually  sufficient  to  start  the  flow,  thereby  relieving  the  cramp. 

Membranous  dysmenorrhea  can  be  cured  by  correcting 
the  disturbances  of  the  uterine  circulation.     This  is  accomplish- 


GENERAL    DISORDERS  OF    MENSTRUATION.  433 

ed  by  correcting  the  bony  lesions  which  are  always  found  in  this 
form  of  dysmenorrhea,  and  by  deep  treatment  over  the  uterus 
to  relieve  the  congestion.  The  writer  treated  a  case  in  which 
the  entire  endometrium  was  cast  off  en  masse.  It  was  a  pear 
shaped  body  with  two  horns  corresponding  to  the  entrance  of  the 
Fallopian  tubes  into  the  uterine  cavity.  This  case  was  cured  by 
a  strong  stimulation  along  the  lower  part  of  the  back,  thereby 
restoring  mobility  to  the  stiffened  vertebral  articulations.  One 
recent  writer  suggests  that  membranous  dysmenorrhea  is  due  to 
a  "  condition  of  widespread  venous  thrombosis  in  the  vessels  of 
the  expelled  mucous  membrane.  This  makes  its  separation  by 
a  process  of  dissecting  hemorrhage  easy  to  understand."  Grant- 
ing this  to  be  true,  the  treatment  would  not  be  changed  from  that 
outlined  above.  The  vaso-motor  centers  are  impaired  by  the 
bony  lesions  which  must  be  corrected  if  a  cure  is  obtained. 

The  use  of  the  curette  is  usually  resorted  to  by  physicians 
to  remove  this  diseased  endometrium,  but  as  mentioned  before. 
I  cannot  see  how  a  healthy  endometrium  will  form  if  the  nutri- 
tion were  not  sufficient  in  the  first  place  to  prevent  the  dis- 
eased condition.  If  the  cause  of  malnutrition  were  removed, 
then  probably  the  theory  would  be  right.  I  have  seen  a  great 
many  cases  of  this  form  of  dysmenorrhea  in  which  the  uterus  had 
been  curetted  and  not  one  of  them  was  benefited,  much  less 
cured. 

In  inflammatory  forms  of  dysmenorrhea  hot  applications 
and  douches  are  usually  advocated,  but  they  give  only  temporary 
relief  and  their  constant  use  weakens  and  lowers  the  vitality  of 
the  uterus  and  vaginal  walls.  Where  there  is  extreme  pain  they 
may  be  resorted  to  if  the  case  can  not  be  otherwise  relieved. 
Hot  drinks  are  beneficial  as  they  alter  the  blood  and  produ<  e 
changes  that  are  helpful. 


434  DISEASES    OF    WOMEN. 

Stenosis  of  the  cervix  is  treated  by  the  introduction  of  a 
uterine  dilator  and  forcibly  dilating  the  os.  I  would  not  like 
to  say  that  this  is  never  indicated,  for  it  may  be  in  some  cases, 
but  these  cases  are  few  and  far  between.  If  scar  tissue  has  form- 
ed around  the  os  thus  lessening  its  lumen,  the  dilator  should  be 
used  to  stretch  it.     This  operation  of  dilatation  is  very  jminful, 


Fig.  103  —uterine  dilator 

injures  the  cervix,  gives  only  temporary  relief,  and  must  be  per- 
formed at  each  menstrual  period.  Inhibition  of  the  clitoris  has 
a  temporary  effect  in  that  it  relieves  the  pain  for  a  short  while. 
Treatment  applied  to  the  fourth  and  fifth  lumbar  and  the  sacrum 
has  a  permanent  effect  by  releasing  the  nerve  force  which  is  in- 
terfered with  usually  at  these  points.  Since  most  cases  are  due 
to  inflammation,  treatment  should  be  applied  to  correct  the 
causes  of  the  inflammatory  condition.  These  causes  are  in  the 
main,  bony  and  muscular  lesions  and  uterine  displacements,  al- 
though other  causes  are  sometimes  found. 

VICARIOUS  MENSTRUATION  is  a  form  of  menstrual  dis- 
order in  which  the  menstrual  flow  or  hemorrhage  during  men- 
struation comes  from  a  part  other  than  the  uterus.  This  may 
entirely  take  the  place  of  normal  menstruation  or  it  may  supple- 
ment it,  this  being  the  more  common.  It  is  a  rare  and  peculiar 
condition,  and  illustrates  the  fact  that  menstruation  is  not  a  local 
process,  but  systemic  in  character. 


GENERAL   DISORDERS  OF   MENSTRUATION  .  435 

The  HEMORRHAGE  may  occur  from  almost  any  mucous  mem- 
brane of  the  body,  usually  from  the  nose,  tonsil,  throat,  gums, 
stomach,  lungs,  bowels  and  breast,  or  from  any  superficial 
ulcer   or  abrasion  of  the  skin. 

Diarrhea  frequently  accompanies  menstruation.  In  the  vi- 
carious type,  this  is  sometimes  very  marked  and  is  of  a  serous, 
bloody  character.  Leucorrhea  is  markedly  increased  and  may 
entirely  take  the  place  of  the  normal  flow.  The  writer  treated 
a  case  in  which  the  hemorrhage  came  from  the  gums.  The  face 
became  spotted,  teeth  ached,  head  was  congested  and  finally 
the  patient  experienced  relief  only  when  the  menstrual  flow  was 
properly  established. 

SYMPTOMS.  The  hemorrhage  occurs  at  the  time  of  the 
menstrual  period  and  is  accompanied  by  the  usual  symptoms  of 
MENSTRUATION.  If  there  is  no  uterine  discharge,  molimina  are 
present.  There  is  congestion,  pain  and  swelling  of  the  part  from 
which  the  flow  comes.  If  the  patient  has  a  sore  on  any  part  of 
the  body  it  becomes  more  congested  and  painful  at  the  time.  I 
have  seen  cases  in  which  the  inflammation  would  extend  to  a 
radius  of  an  inch  from  the  sore.  Such  symptoms,  recurring  at 
regular  intervals  of  four  weeks,  make  the  diagnosis  sure. 

TREATMENT.  Treatment  should  be  directed  to  the  pelvic 
organs.  Some  trouble,  such  as  an  inflammation  or  obstruction 
to  the  escape  of  the  discharge,  is  found  there.  As  a  rule,  the  part 
from  which  the  hemorrhage  comes  is  weak  or  diseased  and  needs 
strengthening  by  treatment.  A  case  of  hematemesis  recently 
came  under  my  care,  in  which  the  menses  would  partly  be  dis- 
charged in  the  normal  way,  then  during  the  latter  part  of  the  per- 
iod the  patient  would  vomit  blood,  while  the  discharge  from  the 
uterus  ceased.  In  this  case  the  treatment  was  applied  to  a  dis- 
placed uterus,  also  to   the  stomach  which  was  weak.     The  real 


436  DISEASES    OF    WOMEN, 

trouble  was  in  the  pelvic  organs,  and  by  correcting  that  disorder 
and  at  the  same  time  strengthening  the  stomach,  the  case  was 
cured. 

PRECOCIOUS  MENSTRUATION  is  a  term  applied  to  men- 
struation occurring  before  puberty,  or  else  a  very  early  puberty. 
Instances  are  on  record  in  which  this  has  occurred  at  the  age  of 
two  years.  There  are  few  symptoms  of  menstruation  other  than 
the  bloody  discharge.  In  some,  the  genital  organs  and  breasts 
are  partially  developed,  and  a  show  of  sexual  passion  is  present. 
In  most  of  these  cases  there  is  a  hemorrhage  rather  than  a  men- 
struation, since  the  usual  local  and  reflex  symptoms  are  absent. 
The  loss  of  blood  weakens  the  system  and  should  be  combatted. 
Masturbation  is  frequently  found  as  the  real  cause  and  steps 
should  be  taken  to  overcome  the  habit,  if  found. 

If  it  occurs  in  a  girl  lacking  a  few  years  of  normal  puberty  it 
indicates  an  early  development  of  the  ovaries,  brought  on  by 
sexual  excitement,  evil  associates  or  the  reading  of  immoral  lit- 
erature. In  such  cases  there  is  marked  development  of  the 
mammary  glands  and  pelvic  organs,  while  the  menstrual  periods 
sre  irregular,  painful  and  profuse. 

DELAYED  MENSTRUATION  is  a  form  of  menstrual  disor- 
der in  which  the  menses  do  not  appear  at  the  fourth  week  but 
are  delayed  several  days,  in  some  cases  nearly  the  entire  month. 
If  delayed  two  months  it  w^ould  be  called  amenorrhea. 

It  is  produced  by  exposure  or  injury  just  before  or  at  the 
time  for  the  appearance  of  the  flow.  A  displaced  uterus  occur- 
ring at  this  time  often  causes  it.  It  produces  pelvic  uneasiness 
with  pain  in  the  abdomen,  back  and  limbs  and  is  sometimes  at- 
tended by  general  soreness  of  the  muscles  of  the  entire  body. 
There  are  molimina  and  a  feeling  as  if  the  flow  might  come  on  at 
any  time.     It  may  give  rise  to  rheumatic  conditions  or,  in  chron- 


GENERAL   DISORDERS    OF    MENSTRUATION.  437 

ic  cases,  the  nervous  form  of  rheumatism  called  rheumatoid 
arthritis. 

A  stimulatmg  treatment  in  the  lumbar  and  sacral  regions 
coupled  with  strong  percussion  of  the  sacrum,  is  generally  suffi- 
cient to  start  the  flow,  and  as  soon  as  it  starts  the  various  pains 
leave.  If  this  is  not  sufficient  sitz  baths,  hot  enemata  and  va- 
ginal .douches  are  helpful  as  auxiliaries.  Sexual  intercourse, 
local  treatment,  inhibition  of  the  clitoris,  all  produce  uterine  con- 
gestion and  dilatation  of  the  os  and  in  many  cases  are  successful 
in  bringing  on  the  flow. 

IRREGULAR  MEXSTRUATIOX  may  be  a  form  of  menor- 
rhagia  or  it  may  occur  without  excessive  flow.  It  dates,  in  most 
cases,  from  puberty,  parturition  or  abortion,  and  depends  upon  a 
disturbed  circulation  or  some  interference  with  the  nerve  centers 
controlling  menstruation  so  that  the  normal  stimulus  is  impaired. 
Lack  of  care,  exposure  and  overwork  and  too  severe  spinal  treat- 
ments all  combine  to  make  menstruation  irregular.  The  inter- 
menstrual period  may  be  two  weeks,  then  five  weeks  in  length, 
the  patient  not  knowing  when  to  expect  the  sick  time.  The 
amount  varies,  being  sometimes  scant,  sometimes  profuse.  Local 
pain,  as  well  as  the  menstrual  reflex  disturbances,  is  usually  ex- 
aggerated. 

In  the  cases  that  have  come  under  my  observation  the  le- 
sions have  been  at  the  sacro-iliac  synchondrosis,  there  being 
either  a  slipped  innominate  or  sacrum.  The  form  which  dates 
from  puberty  is  probably  due  to  interference  with  the  proper 
development  of  the  uterus  or  ovaries,  more  frequently  the  latter. 
Displacements  and  subinvolution  following  abortion  may  lead  to 
an  irregular  menstruation. 

The  treatment  depends  upon  the  lesions  found  in  the  indi- 


438  DISEASES    OF    WOMEN. 

vidual  case.     If  the  circulation  and  nerve  supply  can  be  adjusted, 
the  case  can  be  cured. 

PROTRACTED  MENSTRUATION.  If  menstruation  is  pro- 
tracted beyond  the  age  of  forty-five  it  is  regarded  as  abnormal  if 
accompanied  by  other  symptoms.  In  some  cases  it  is  the  result 
of  continued  activity  of  the  ovaries  and  is  not  pathological;  in 
others  it  is  the  result  of  some  abnormal  stimulation  of  the  ovaries 
or  uterus,  and  is  then  pathological.  It  may  persist  as  late  as 
fifty  years  and  impregnation  take  place,  but  this  is  the  exception 
and  occurs  in  few  cases.  After  the  age  of  forty-eight  the  pres- 
ence of  menstruation  is,  in  many  cases,  indicative  of  malignancy, 
and  care  should  be  taken  to  ascertain  the  character  of  the  dis- 
charge, odor  and  amount.  Protracted  menstruation  is  only  a 
symptom  and  in  ordinary  cases  does  not  need  treatment,  but  if 
the  hemorrhage  is  too  profuse  and  there  are  reflex  pains,  or  if 
there  are  symptoms  of  cancer  or  other  malignant  growths,  it 
should  be  checked  if  possible. 


DISEASES    OF    THE    FALLOPIAX    TUBES.  439 


DISEASES  OF  THE  FALLOPIAN  TUBES. 

THE  FALLOPIAX  TUBES.  The  anatomy  of  the  tubes  has 
been  considered.  Functionally  they  act  as  ducts  along  which 
the  ova  and  spermatozoa  pass,  and  also  serve  as  receptacles  for 
both  the  ovum  and  spermatozoon.  They  also  take  part  in  the 
menstrual  process,  the  epithelial  cells  as  well  as  a  bloody  secre- 
tion, being  cast  off.  I  have  seen  cases  of  membranous  dys- 
menorrhea in  which  there  was  a  cast  of  the  tubes  about  one-half 
inch  long.  It  was  very  fragile,  probably  a  portion  had  been 
broken  off  in  its  passage.  From  this  it  would  seem  that  they  are 
important  factors  in  menstruation.  Again,  post  mortem  ex- 
aminations have  been  held  in  women  who  died  during  the  men- 
strual flow  and  blood  was  found  in  the  tubes,  but  in  these  cases 
it  could  have  been  forced  back  into  the  tubes  from  the  utervis. 
Ectopic  gestation  most  frequently  occurs  in  the  tubes,  the  diag- 
nosis of  which  will  be  considered  separately. 

DISEASES  of  the  tubes  include  malformations,  occlusion, 
congestion,  displacements,  inflammatory  conditions  and  new 
growths.  There  may  be  arrest  of  development  due  to  some  ab- 
normality of  the  Mullerian  ducts,  resulting  in  an  absence  of  tun- 
neling or  a  total  absence  of  one  of  the  ducts.  Again,  the  tubes 
may  be  open  at  the  uterine  end  with  a  constriction  at  the  middle 
portion.  In  such  cases  there  is  found  an  undersized  and  non- 
developed  ovary  on  the  same  side.  The  malformations  give  rise 
to  pain  at  the  menstrual  time,  sterility,  or  local  peritonitis  re- 
sulting from  the  ova  and  blood  dropping  back  into  the  peri- 
toneal cavity. 

INFLAMMATION  of  the  Fallopian  tubes  is  called  salpingi- 


440  DISEASES    OF    WOMEN. 

tis.  It  is  rarely  found  as  a  separate  disease  but  is  most  frequently 
found  in  connection  with  ovaritis  or  endometritis.  The  disease  is 
usually  unilateral,  the  left  side  being  attacked  more  frequently 
than  the  right.  The  mucous  membrane  swells,  this  depending 
in  amount  on  the  degree  of  inflammation  and  the  cilia  are  ab- 
sorbed or  destroyed,  at  least  their  function  is  perverted.  An 
EXUDATE  follows  the  congestion,  which  serves  to  agglutinate 
the  tube  to  adjacent  structures,  principally  the  peritoneum.  This 
condition  continues  until  adhesions  are  formed,  drawing, 
TWISTING  and  securely  binding  the  tubes,  ovaries  and  broad  lig- 
aments   INTO    ONE    INFLAMED    CONGLOMERATE    MASS.       In    marked 

cases  pus  forms  and  is  forced  out  into  the  abdominal  cavity; 
localized  peritoneal  adhesions  form  and,  if  the  condition  con- 
tinues, extensive  pelvic  peritonitis,  with  its  inflammatory  exu- 
dates, follows.  In  cases  due  to  infection  such  as  gonorrheal  in- 
flammation, pus  usually  forms.  The  ostium  abdominale  closes 
and  the  pus  is  retained,  thus  forming  a  pus  sack  or  pyo-salpinx. 

These  tubal  inflammations  are  variously  classified  but  are 
most  commonly  divided  into  acute,  chronic  and  infectious. 

Acute  salpingitis  may  be  the  result  of  ovaritis  or  endome- 
tritis. A  sudden  stoppage  of  the  menstrual  flow,  especially  from 
exposure  or  cold,  is  followed  in  most  cases  by  inflammation  of  the 
tubes.  Labor,  and  especially  abortion,  afTects  the  tubes  either 
from  trauma  or  infection  during  the  puerperium.  The  use  of  the 
uterine  sound  sometimes  produces  acute  salpingitis. 

Gonorrheal  infection  may  set  up  an  acute  inflammatory 
process,  put  this  is  more  often  chronic.  This  cause  is  a  very  im- 
portant one  in  chronic  cases.  The  disease  extends  by  continu- 
ity of  tissue  to  the  Fallopian  tubes  and  ovaries,  and  when  once 
the  gonococci  reach  the  tubes  a  cure  is  well  nigh  impossible.  No 
form  of  douche  will  reach  the  seat  of  the  disease  and  one  has  to 


DISEASES    OF   THE    FALLOPIAN    TUBES.  441 

rely  on  the  germicidal  action  of  the  blood  to  rid  the  tube  of  these 
micro-organisms.  I  have  examined  many  women  who  had  this 
type  of  SALPINGITIS  as  a  result  of  conjugal  relations  with  a  hus- 
band who  had  latent  gonorrhea.  In  the  early  stages  there  is 
a  vaginitis  with  altered  secretion.  This  gradually  disappears 
but  the  patient  complains  of  ovarian  trouble,  and  on  examina- 
tion the  uterus,  ovaries  and  tubes  are  tender.  This  continues 
for  months  and  finally  the  disease  becomes  localized  in  the  tubes 
and  ovaries  and  a  discharge  sets  in  which  is  worse  during  men- 
struation; the  tubes  enlarge,  remain  tender,  and  the  slightest 
pressure  over  them  is  productive  of  pain. 

Any  other  condition  causing  an  acute  endometritis  such  as 
the  use  of  the  sound,  dilator,  tent  or  medicated  douches,  will 
produce  salpingitis.  If  a  douche  is  forcibly  introduced  into  the 
uterus  it  is  likely  that  the  fluid  will  be  carried  through  the  Fal- 
lopian tubes  into  the  peritoneal  cavity  and  cause  hiflammation 
of  the  tubes,  ovaries  and  peritoneum. 

In  cases  of  salpingitis  the  mucous  membrane  swells,  the 
tubes  thicken  and  an  intense  pain  is  located  just  to  the  side  of  the 
uterus.  This  pain  is  acute,  lancinating  or  colicky,  or  in  some 
cases  simply  an  ache.  The  patient  walks  very  carefully  and 
avoids  shaking  or  jarring  of  the  body,  the  least  motion  of  the  parts 
exciting  pain.  Coitus,  coughing,  sneezing,  or  anything  moving 
the  tubes  either  directly  or  indirectly  through  a  change  in  the 
intra-abdominal  pressure,  will  bring  on  pain.  On  palpation 
there  is  great  tenderness  over  the  tubes  and,  if  there  is  not  too 
much  inflammation,  the  enlarged  tubes  can  be  felt  through  the 
abdominal  wall,  in  some  cases  they  being  almost  as  large  as  the 
finger.  There  is  scanty  menstruation  unless  it  has  been  entirely 
checked.  Dysmenorrhea  is  also  present,  it  being  both  of  the 
ovarian  and  inflammatory  type. 


442  DISEASES   OF    WOMEN. 

CHRONIC  SALPINGITIS  may  follow  the  acute  attack  or  it 
may  occur  independently.  Lesions  producing  chronic  pelvic 
inflammations  also  produce  salpingitis,  such  lesions  being  found 
usually  in  the  lumbar  region.  The  continued  conc4ESTion  and 
inflammation  tend  to  produce  a  constriction  or  narrowing  of  the 
canal  and  adhesions  are  often  found.  The  secretions  are  affected, 
in  many  cases  pus  collects  in  the  tubes  producing  the  condition 
of  pyo-salpinx.  This  causes  an  enlargement  of  the  tubes  which 
might  be  mistaken  for  an  ovarian  tumor. 

The  symptoms  of  salpingitis  are  tenderness  over  the  course 
of  the  tubes,  and  pain  on  the  least  jar  of  the  body,  such  as  would 
result  from  riding  over  rough  roads  or  from  running  or  walking 
rapidly.  Leucorrhea  is  found,  but  this  is  due  rather  to  the  co- 
existing congestion  and  inflammation  of  the  uterus  than  to  the 
salpingitis.  Pain  is  increased  at  the  menstrual  period  although 
there  is  a  constant  feeling  in  the  side  as  if  something  were  pulling 
down  on  the  ovary.  The  menses  are  affected  as  to  amount,  there 
being  an'  increased  flow  as  the  result  of  congestion.  On  palpa- 
tion in  the  pouch  of  Douglas,  an  inflamed  mass  of  tissue  can  be 
felt.  This  enlargement  is  composed,  in  most  cases,  of  the  tube, 
ovary,  broad  ligament  and  an  inflammatory  exudate  which  firm- 
ly holds  the  different  structures  together. 

The  latent  form  of  gonorrhea  as  mentioned  above  is  a  very 
common  cause  of  the  chronic  form  of  salpingitis.  The  patient's 
HEALTH  IS  undermined  and  she  suffers  with  female  W'Eakness. 
There  is  chronic  backache  and  sideache,  and  the  abdomen  is  very 
tender. 

Salpingitis  is  very  hard  to  diagnose  from  ovarian  and  uterine 
disease,  but  there  is  little  use  in  so  doing  as  the  causes  are  sim- 
ilar and  treatment  about  the  same.  Sometimes  tubal  disease  is 
mistaken   for  appendicitis,   if  the  right  tube  is   affected.     The 


DISEASES    OF   THE    FALLOPIAN   TUBES.  443 

diagnosis  can  be  cleared  up  by  noting  the  position  of  the  mass 
and  by  local  vaginal  examination  in  which  the  tube  can  be  reached. 
The  treatment  consists  of  correcting  the  uterine  and  ovarian 
displacement  in  order  to  remove  the  traction  which  is  exerted 
on  the  tubes.  Also  correct  bony  lesions  which  interfere  with  the 
blood  and  nerve  supply  to  the  parts,  or  that  affect  the  broad  lig- 
aments. Treatment  applied  over  and  around  the  tubes  is  some- 
times beneficial  in  that  it  helps  to  relieve  the  congestion  of  these 
parts.  Operations  for  the  removal  of  the  tubes  are  resorted  to 
by  surgeons.  In  some  cases,  such  as  a  marked  condition  of 
pyo-salpinx,  it  is  indicated,  but  in  a  great  majority  of  cases  the 
disease  can  be  cured  by  osteopathic  methods  and  the  operation 
avoided. 


444  DISEASES    OF    WOMEN. 


OVARIAN  DISEASES. 


THE  OVARIES  are  the  most  important  of  the  pelvic  organs, 
and  exert  a  predominating  influence  over  the  rest  of  the  geni- 
talia. 

By  reference  to  their  anatomy  we  find  that  they  are  oblong 
bodies  located  one  on  either  side  of  the  uterus  and  held  in  place 
by  the  ovarian,  infundibulo-pelvic  and  broad  ligaments,  being 
imbedded  in  the  walls  of  the  posterior  layer  of  the  last  named  lig- 
ament. 

Their  development  occurs  at  puberty,  at  which  time  they 
commence  to  perform  their  function,  that  is,  ovulation  and  men- 
struation begin.  Prior  to  this  the  ovaries  have  no  function, 
hence  are  undeveloped  and  inactive.  Disease,  except  that  re- 
sulting from  an  error  in  development,  seldom  attacks  them  be- 
fore puberty.  They  sometimes  retain  their  infantile  form  and 
size.  In  such  cases  they  are  elongated  and  extend  along,  and 
apparently  constitute  a  part  of,  the  Fallopian  tubes.  This  pecvi- 
liarity  is  so  marked  in  some  cadavers  that  it  is  hard  to  differen- 
tiate between  tubes  and  ovaries. 

The  ovary,  like  other  internal  organs,  is  subject  to  disease. 
Primary  diseases  of  these  organs  are  rare,  but  secondary  diseases 
frequently  and  readily  attack  them.  The  principal  diseases  are 
displacement,  inflammation  and  tumors;  while  in  some  malfor- 
mations and  non-development  are  found,  in  which  cases  there  is 
sterility  and  menstrual  disorders. 

DISPLACEMENT  of  the  ovary  is  met  with  most  frequently 
as  the  result  of  a  displaced  uterus  or  broad  ligament.  In  some 
cases  it  becomes  displaced  independently  of  the  uterus,  as  a  re- 


OVARIAN    DISEASES.  445 

suit  of  stretching  and  elongation  of  its  ligaments.  Such  cases 
are  seldom  pathological,  thus  giving  rise  to  few,  if  any,  symp- 
toms. Since  the  ovary  is  imbedded  in  the  posterior  wall  of  the 
broad  ligament,  anything  which  displaces  this  ligament    would 


Fig.  104  — Showing  proliipstiH  of  ovary  and  tube  into  the  pouch  of  DouglaH. 

displace  the  ovary,  hence  in  all  uterine  displacements  the 
ovary  is  of  necessity  displaced,  the  amount  of  displacement  de- 
pending upon  the  degree  of  the  uterine  displacement,  the  amount 


446  DISEASES    OF    WOMEN. 

of  relaxation  of  the  ovarian  ligaments,  and  weight  of  the  ovary. 
The  primary  form  is  due  to  enlargement  of  the  ovary  in  which 
the  weight  is  considerably  increased.  This  increase  in  size  may 
be  caused  by  congestion  or  a  tumor.  Excessive  venery  is  re- 
sponsible for  a  large,  flaccid  ovary  with  weakened,  easily  stretch- 
ed ligaments.  The  repeated  congestions  from  coitus  finally  lead 
to  a  chronic  congestion  with  its  hyperplasia,  or  to  inflammation 
with  its  cell  proliferation. 

In  cases  of  acute  retroflexion,  the  ovaries  are  pulled  down 
into  the  pouch  of  Douglas  where,  by  rectal  or  vaginal  examina- 
tion, they  can  be  felt  as  tender  bodies.  In  such  cases  defeca- 
tion IS  painful  as  the  contents  of  the  bowel  in  passing  through 
the  rectum  must  impinge  on  the  ovary.  In  many  cases  of  dis- 
placed uterus  the  pain  is  referred  to  the  side  or  region  of  the  ovary. 
There  is  nausea  and  even  vomiting  in  some  cases,  probably  due 
to  pressure  on  or  other  disturbance  of  the  ovary.  Pressure  on 
the  testicle  in  the  male,  has  a  similar  effect.  In  such  cases  of 
displacement,the  ovarian  irritation  is  the  real  cause  of  the  cramp- 
ing in  the  side  referred  to  above.  Pressure  exerted  directly 
ON  the  congested,  displaced  ovary,  causes  a  sickening  pain  like 
that  resulting  from  pressure  on  a  floating  kidney. 

Relaxation  of  the  ligaments  and  supports  of  the  ovary  also 
cause  its  displacement.  In  pregnancy  the  ovaries  are  drawn  up- 
ward and  all  the  structures  surrounding  them  are  stretched.  If 
a  condition  of  subinvolution  follows  parturition,  the  ovaries  are 
not  drawn  back  into  their  position  but  remain  in  an  abnormal 
position.  In  such  cases  the  uterus  is  large  and  soft,  the  vaginal 
walls  relaxed,  tubes  thickened,  there  is  a  chronic  ache  in  the 
sides  and  the  pain  is  referred  to  the  ovaries.  The  ovary  may 
sink  by  its  increased  weight  when  it  enlarges,  as  from  congestion 
or  the  presence  of  a  growth.     The  left  is  more  frequently  pro- 


OVARIAN    DISEASES.  447 

lapsed  than  the  right,  since  it  is  the  weaker  of  the  two.  Ad- 
hesions which  result  from  chronic  peritonitis  often  pull  the  ovary 
out  of  place  or  cause  a  sense  of  tightness  in  that  region. 

The  symptoms  of  prolapsed  ovary  are  tenderness  and  pain 
over  and  around  the  ovary,  the  pain  in  some  cases  being 
acute,  either  shooting  toward  the  umbilicus  or  down  the  limb. 
Any  motion  or  jarring  of  the  part  increases  the  pain.  In  recent 
cases  there  are  frequently  functional  derangements  of  the  nerv- 
ous system.  In  a  thin  subject  the  ovary  can  be  felt  by  rectal 
or  bimanual  examination,  it  being  recognized  by  its  shape,  ten- 
derness and  the  nauseating  sensation  from  pressure  exerted^on  it. 

It  is  diagnosed  from  fecal  impaction  by  its  shape,  location 
and  the  character  of  pain  resulting  from  pressure.  A  small 
fibroid  is  less  movable,  not  tender  and  is  complicated  by  men- 
strual disorders,  usually  menorrhagia.  An  ovarian  cyst  is 
larger,  fluctuates  and  rapidly  increases  in  size. 

Many  forms  of  disease  of  distant  organs  result  from  displace- 
ment of  the  ovaries,  especially  if  some  inflammation  complicates 
the  prolapsus.  The  most  common  reflex  trouble  is  pain  in  the 
iliac  fossa  in  that  part  supplied  by  the  tenth  and  eleventh  inter- 
costal nerves.  The  irritation  of  the  ovary  resulting  from  its  dis- 
placement aff"ects  the  ovarian  plexus  of  nerves,  which  in  turn 
affects  the  tenth,  eleventh  and  twelfth  segments  of  the  thorac- 
ic cord.  Therefore,  impulses  arising  in  the  ovarian  plexus  reach 
the  spinal  cord.  Applying  Head's  law  we  find  that  the  irrita- 
tion or  pain  is  referred  to  the  area  supplied  by  the  cerebro-spinal 
nerves  with  which  the  ovarian  plexus  is  connected,  viz.,  the 
tenth,  eleventh  and  twelfth  thoracic  nerves.  The  point 
of  greatest  pain  is  in  a  small  area  on  a  level  with  and  immediately 
internal  to  the  anterior  superior  spine  of  the  ilium.  The  con- 
stant aching  referred  to  the  side,  is  a  common  accompaniment  of, 
or  sequel  to,  prolapsus  of  the  ovary  with  congestion. 


448  DISEASES    OF    WOMEN. 

Pain  in  the  knee  with  or  without  synovitis  has  occurred  in 
the  author's  practice.  In  some  cases  the  knee  was  very  much 
enlarged  from  an  effusion.  Replacement  of  the  uterus  and  ovary 
on  the  affected  side,  reduced  the  swelling  and  relieved  the  pain. 
Another  case  came  under  my  care — synovitis  of  the  knee  with 
partial  ankylosis  of  the  joint  following  an  attempted  abortion  in 
which  the  ovary  was  injured. 

The  stomach  is  the  most  frequently  affected  of  all  the  vis- 
cera. Nausea  and  vomiting  occur  at  irregular  intervals,  and  in- 
digestion with  flatulency  is  often  found  as  a  complication.  A 
displaced  uterus,  if  occurring  suddenly,  produces  intense  nausea. 
This  is  due  in  part,  if  not  entirely,  to  the  sudden  ovarian  displace- 
ment. 

Hystero-epilepsy  constitutes  one  of  the  most  interesting  of 
the  complications  of  ovarian  displacement.  In  such  cases  the 
attack  is  heralded  by  the  formation  of  a  "knot"  or  "lump" 
which,  starting  somewhere  in  the  abdominal  region,  gradually 
ASCENDS  until  it  reaches  the  heart  or  throat,  at  which  time  the 
patient  suddenly  loses  consciousness.  This  peculiar  movable 
lump  is  a  fairly  reliable  indication  of  ovarian  disease,  most  com- 
monly a  displacement.  Hysteria  is  often  manifest  by  this  "  lump ' ' 
in  the  throat  which  can  not  be  swallowed.  Ovarian  displace- 
ment is  commonly  found  in  hysterical  patients. 

Dr.  Harvey  Mayer  reported  to  me  a  case  of  epilepsy  dating 
from  parturition,  which  was  cured  by  replacement  of  a  prolasped 
ovary.  The  case  was  one  of  several  years  standing  and  had  not 
been  benefited  by  any  form  of  treatment  prior  to  this. 

TREATMENT  consists  of  first  reducing  the  uterine  trouble. 
If  there  is  subinvolution,  endeavor  to  restore  the  normal  circu- 
lation by  correcting  bony  lesions,  and  the  uterine  displacement, 
and  by  abdominal  treatments,  to  lift  up  the  intestines  in  order  to 
relieve  congestion  of  the  uterus. 


OVARIAN    DISEASES.  449 

Gentle  pressure  directed  against  the  ovary  when  the  pa- 
tient is  in  the  knee-chest  position,  by  means  of  the  finger  placed 
in  the  posterior  fornix,  will  cavise  it  to  assume  its  normal  posi- 
tion unless  held  down  by  adhesions  or  an  irreducibly  displaced 
uterus.  If  adhesions  exist  they  can  be  broken  up  by  repeated  at- 
tempts at  replacement  of  ovary  and  uterus.  It  must  be  borne 
in  mind  that  the  ovary  is  a  very  sensitive  organ  even  in  its 
normal  condition,  and  especially  so,  when  displaced  and  inflamed. 
This  being  the  case  a  very  gentle  force  should  be  used  when  re- 
placing or  palpating  it.  Rest,  both  physical  and  sexual,  should 
be  demanded,  since  either  one  tends  to  irritate  and  make  worse 
this  condition. 

CONGESTION  OF  THE  OVAKY  is  probably  the  most  fre- 
quent of  all  ovarian  affections.  It  is  rare  to  find  a  woman  who 
does  not  have  pain  or  tenderness  in  the  region  of  the  ovary  either 
constantly  or  during  the  menstrual  period.  This  congestion 
may  be  primary  or  secondary.  In  the  young  it  is  usually  pri- 
mary; in  multipara,  secondary. 

The  mind  has  a  great  deal  to  do  with  the  sexual  organs,  and 
since  the  ovaries  are  the  most  important  of  these  organs,  in  that 
they  control  and  regulate  the  function  of  the  other  pelvic  vis- 
cera, it  follows  that  they  are  the  most  influenced  by  the  mind. 
Stimulation  of  the  higher  centers,  which  are  supposed  to  be  in 
the  cerebellum,  produces  ovarian  congestion.  This  is  manifest 
in  the  ache  of  the  ovary  following  ungratified  sexual  de- 
sire, which  is  the  most  common  cause  of  ovarian  congestion  in 
nullipara,  and  is  followed  by  varicosities  of  the  veins  in  the 
broad  ligaments,  and  usually  by  ovaritis.  If  this  .occurs  repeat- 
edly, the  ovary  must  of  necessity  become  diseased.  An  analo- 
gous condition  is  found  in  the  male,  as  is  indicated  by  the  aching 
tender  testicle   followed   by  varicocele,  if  the  congestion  occurs 


450  DISEASES   OF    WOMEN. 

repeatedly.  If  there  has  been  sexual  excitement  the  activity 
of  the  ovaries  is  increased  by  it  and  whenever  this  occurs,  as  is 
the  case  when  the  activity  of  any  organ  is  increased,  congestion 
follows.  Hence  it  follows  that  anything  which  increases  sexual 
desire,  whether  it  comes  from  immoral  associations,  impure  liter- 
ature or  a  lesion  which  stimulates  the  pudic  nerve  or  pelvic 
plexus  or  nerves,  excites  ovarian  congestion. 

A  slipped  rib,  either  by  pressing  on  the  structures  over  the 
ovaries  or  interfering  with  the  rami  communicantes  of  the  sym- 
pathetic, often  CAUSES  ovarian  congestion.  The  ganglionic 
sympathetic  chain  lies  on  or  near  the  iieads  of  the  ribs,  conse- 
quently a  slight  displacement  of  the  lower  ribs  will  often  disturb 
the  connection  existing  between  the  cerebro-spinal  and  sympa- 
thetic nervous  systems. 

Displacements  of  the  ninth,  tenth  and  eleventh  dorsal  verte- 
brae, cause  ovarian  congestion  by  affecting  the  vaso-motor  cen- 
ters of  the  ovaries.  These  centers  are  located  in  the  lower 
thoracic  segments  of  the  spinal  cord  and  connect  with  the 
OVARIES  by  way  of  the  white  rami,  sympathetic  ganglia,  efferent 
nerves,  which  are  the  lesser  and  least  splanchnics  and  renal  plexus, 
thence  by  way  of  the  ovarian  plexus  to  the  ovary.  These  ver- 
tebral lesions  affect  (1)  the  nerves  in  the  corresponding  foramina 
and  (2)  the  blood  supply  to,  and  drainage  of,  these  spinal  seg- 
ments, so  if  these  nerve  cells  are  affected  in  any  way,  the  impulses 
arising  from  them  would  be  disturbed.  One  of  the  functions  of 
these  cells  is  vaso-motor,  hence  a  disturbance  results  in  an  alter- 
ation of  the  amount  of  blood  in  the  ovary.  The  best  explana- 
tion of  the  effect  on  these  cells,  from  the  writer's  experience,  is 
that  the  lesions  impair  the  nutrition  of  the  cells  by  affecting 

NORMAL  CIRCULATION  TO  THEM. 

Displacements  of  the  uterus  or  prolapsus  of  the  ovaries  is 


OVARIAN    DISEASES.  451 

accompanied  by  congestion  and,  in  most  cases,  inflammation 
which  may  extend  from  the  tubes  to  the  ovaries  as  a  result  of 
chronic  congestion  of  both. 

Intestinal  prolapsus  causes  a  venous  stagnation  in  the 
ovaries  from  pressure  on  the  ovarian  veins.  These  veins  are 
very  long  and  yield  to  a  very  slight  pressure. 

The  symptoms  vary  with  the  degree  and  kind  of  congestion. 
If  it  is  active  there  is  a  burning,  aching,  throbbing  sensation, 
acute  or  lancinating  pain,  followed  by  a  dull  ache  in,  and  tender- 
ness over  the  ovary,  as  the  active  congestion  becomes  passive. 
If  a  passive  congestion,  there  is  a  sense  of  weight  and  heaviness 
in  the  affected  side. 

ACUTE  OVARITIS  is  most  commonly  associated  with  acute 
salpingitis,  especially  the  form  due  to  gonorrhea  and  acute 
METRITIS.  Sometimes  it  is  found  in  the  puerperal  state.  Sud- 
den suppression  of  the  menses  causes  ovaritis  as  well  as  salpin- 
gitis. In  cases  of  pelvic  peritonitis  from  other  causes  the  inflam- 
mation extends  to  the  ovary  and  there  sets  up  an  acute  inflam- 
matory condition. 

Most  writers  on  the  subject  claim  that  ovaritis  is  due  to 
microbic  infection.  Perhaps  this  is  true  of  the  gonorrheal  type 
of  ovaritis  but  I  think  this  not  true  of  the  ordinary  forms.  If 
microbes  are  found,  that  alone  does  not  prove  them  to  be  the 
cause,  but  it  does  prove  that  the  tissues  are  devitalized  to  such 
a  degree  that  the  organism  can  not  repel  the  invaders. 

Repeated  congestion  of  the  ovary,  especially  that  due  to  un- 
gratified  sexual  excitement,  is  the  most  prolific  of  all  causes.  The 
ovary  remains  congested  for  days  and  the  patient  complains  of  a 
constant  ache  in  the  side. 

In  considering  the  pathology  of  acute  ovaritis  the  changes 
are  similar  to  those  in  anv  acute  inflammation.     The  ovarv  is 


452  DISEASES    OF    WOMEN. 

swollen,  softened  and  the  blood  vessels  engorged.  There  is  often 
a  plastic  exudate  which  covers  the  ovary,  finally  resulting  in  the 
formation  of  adhesive  bands.  This  exudate  entirely  surrounds 
the  ovary  and  in  many  cases  hides  it  from  view  when  the  pelvic 
cavity  is  opened.  The  tubes  and  ligaments,  particularly  the 
broad  ligaments,  are  usually  involved. 

Acute  ovaritis  may  be  secondary  to  mumps,  if  the  patient 
exercises  too  soon  after  an  attack.  What  the  connection  is  be- 
tween the  parotid  gland  and  the  ovary  the  writer  will  not  attempt 
to  explain,  but  it  is  well  known  that  there  is  a  close  sympathy 
between  the  glantl  and  pelvic  viscera.  This  is  partly  proven  by 
the  fact  that  there  is  ptyalism  in  the  early  stages  of  pregnancy 

The  symptoms  can  not  be  differentiated  from  those  of  sal- 
pingitis or  a  localized  peritonitis.  There  is  a  burning  pain  over 
the  ovary,  often  radiating  to  the  limb  on  the  affected  side,  which 
results  in  a  contraction  and  drawing  up  of  the  limbs.  The  ab- 
domen is  extremely  tender  to  touch,  which  is  indicative  of  a  per- 
itonitis. On  palpation  there  is  usually  found  a  tender  inflamed 
MASS  BACK  of  and  to  one  side  of  the  uterus.  This  mass  is  fixed 
and  consists  of  the  tube,  ovary  and  a  pelvic  exudate, 
all  of  which  are  bound  together,  making  it  hard  to  outline  any 
one  of  them.  In  the  early  stages  the  ovary  can  be  outlined, 
it  being  exquisitively  tender  to  the  touch  and  much  swollen. 

The  treatment  for  temporary  relief  is  to  work  out  the  inflam- 
mation by  commencing  at  the  edge  of  the  inflammatory  area  and 
gradually  working  up  to  the  seat  of  inflammation.  Treatment 
should  not  be  given  over  the  inflamed  area  at  first  as  there  is 
danger  of  increasing  the  irritation.  The  muscles  along  the  back 
should  be  relaxed,  since  in  almost  every  case  they  are  badly  con- 
tractured.  Rest  should  be  advised,  the  patient  being  allowed 
on  her   feet  but  very  little.     Coition  is  ppinful   and  should  be 


OVARIAX    DISEASES.  453 

prohibited.  In  some  of  my  cases  I  have  found  a  slight  twist  of 
the  lower  dorsal  vertebrae,  and  by  correcting  this  instant  relief 
was  obtained.  If  the  ovarian  inflammation  is  a  complication  of 
uterine  disease,  such  as  acute  metritis,  the  primary  or  curative 
treatment  should  be  applied  to  the  uterine  disease.  Replace- 
ment, with  the  starting  of  the  menstrual  flow,  are  the  best  treat- 
ments FOR  ACUTE  METRITIS  and  Will  relieve  the  intense  ovarian 
CONGESTION  and  infla:mmation. 

CHRONIC  OVARITIS,  or  oophoritis,  frequently  follows  the 
acute  form,  especially  the  primary  acute  ovaritis  resulting  from 
congestion  of  the  ovary.  The  continued  hyperemia  at  last  re- 
sults in  degenerative  and  inflammatory  changes  which,  after  a 
while,  are  followed  by  the  chronic  form  of  inflammation. 

Displacements  of  the  ovaries  lead  to  congestion  and  finalh' 
to  chronic  oophoritis.  Chronic  uterine  inflammation  extends  to 
the  ovary  and  there  sets  up  inflammatory  changes;  chronic  sal- 
pingitis produces  a  similar  condition;  latent  gonorrhea,  by  caus- 
ing a  chronic  salpingitis,  produces  the  chronic  form  of  oophoritis. 
Some  of  the  worst  cases  of  ovarian  inflammation  result  from  gonor- 
rheal infection  by  the  husband  who  had  latent  gonorrhea.  The 
urethritis  was  supposed  to  have  been  cured  but  occasionall}' 
there  would  be  a  slight  discharge  if  the  patient  strained  at  stool 
or  in  micturition,  and  especially  in  the  morning.  After  infecting 
the  wife  the  disease  gradually  ascends  until  it  reaches  the 
ovaries.  Chronic  inflammation  follows  with  a  discharge  of  a 
VERY  irritating  CHARACTER.  In  SO  me  it  is  so  intensely  acid 
that  it  erodes  the  tissues  with  which  it  comes  in  contact. 
The  ovary  at  first  hypertrophies,  softens,  then  the  interstitial 
growth  increases  from  the  inflammatory'  exudate,  after  which, 
in  favorable  cases,  it  gradually  shrinks  and  becomes  very  small 
and  hard. 


454  DISEASES    OF    WOMEN. 

The  OVARY  is  sometimes  injured  during  childbirth.  If 
prolapsed  it  is  compressed  between  the  fetal  head  and  brim  of  the 
pelvis  and  is  bruised  if  not  badly  injured.  This  is  followed  by 
inflammation  and,  in  severe  cases,  pus  formation  with  chronic 
discharge. 

Lesions  along  the  lower  dorsal  region,  such  as  any  form  of 
curvature,  a  twisted  vertebra  or  a  displaced  rib,  are  the  prin- 
cipal CAUSATIVE  FACTORS.  If  these  lesions  exist,  as  weakening 
or  predisposing  causes  by  which  the  organs  lose  some  of  their 
power  of  combating  disease,  then  an  inflamed  or  displaced  uterus 
or,  in  fact,  any  exciting  cause,  acts  the  more  readily. 

From  a  pathological  standpoint,  the  stroma  is  most  involved, 
but  the  parenchyma  may  be  affected.  There  is  formation  of 
NEW"  CONNECTIVE  TISSUE,  in  fact  an  overgrowth  with  hypertro- 
phy of  its  follicles,  from  which  there  often  develops  retention 
cysts,  thus  forming  the  cystic  ovary;  the  blood  vessels  are  en- 
larged and  their  walls  thickened.  The  whole  ovary  is  en- 
larged and  frequently  surrounded  by  peritoneal  adhesions  which 
securely  attach  it  to  adjacent  structures. 

SYMPTOMS.  In  chronic  ovaritis  there  is  pain  and  tender- 
ness in  the  region  of  the  ovary,  the  sore  spot  being  just  on  a 
level  with  the  anterior  superior  spine.  This  has  been  ex- 
plained before  as  due  to  the  distribution  of  the  tenth  and  eleventh 
thoracic  nerves  which  are  derived  from  the  same  segment  that  sup- 
plies the  ovary,  hence  the  reflex  phenomenon. 

The  deep  muscles  of  the  lower  thoracic  region  and  of  the 
abdomen  are  often  contractured,  the  patient  complaining  of  a 
drawing  sensation.  In  the  early  stages  the  ovaries  may  be  felt 
as  oblong,  tender  bodies,  deep  down  in  the  pelvis.  The  lym- 
phatic glands  which  drain  the  ovaries  are  enlarged  and  tender, 
and  the  iliac   artery  on  the  same   side   frequently  much  in- 


OVARIAN    DISEASES.  455 

creased  in  size.  I  have  seen  cases  in  which  the  left  iliac  artery 
was  TWICE  the  size  of  the  right,  being  tense  and  pulsating  very 
hard.     The  left  ovary  was  much  inflamed  in  these  cases. 

In  other  cases  the  pain  will  be  referred  to  the  navel,  and  in 
such  it  is  hard  to  differentiate  from  abdominal  troubles.  Pain 
is  also  found  in  the  side  and  radiating  to  the  back.  A  slipped  rib 
is  nearly  always  responsible  for  this  kind,  and  the  clothing  or  a 
tight  belt  causes  intense  pain  over  the  ends  of  the  lower  ribs. 

The  mammary  glands  are  often  tender  and  swollen,  and  in 
some  cases  there  are  symptoms  of  mastitis  or  even  malignant 
diseases.  Lumps  or  tumors  form  in  the  gland  and  cause  a  great 
deal  of  fear  and  annoyance.  In  some  the  nipples  are  inverted, 
that  is,  instead  of  an  elevation  or  protuberance  there  is  a  depres- 
sion. This  is  indicative  of  ovarian  diseases,  usually  a  chronic 
inflammation  on  the  same  side,  but  the  converse  is  not  neces- 
sarily true,  that  is,  an  inverted  nipple  is  not  always  found  in 
ovarian  disease.  Remember  that  there  is  close  sympathy  be- 
tween the  mammary  glands  and  the  generative  organs,  in  fact 
these  glands  should  be  classed  as  appendages  of  the  pelvic  organs 
since  their  function  is  dependent  on  the  function  of  the  genera- 
tive organs.  Ovarian  activity  causes  an  enlarged  breast 
and  in  pregnancy  the  glands  are  active  in  milk  secretion. 

Menstrual  disorders  follow  chronic  ovaritis;  menorrhagia 
being  the  most  common  at  first,  but  as  the  inflammation  pro- 
gresses the  flow  becomes  scanty,  finally  resulting  in  amenorrhea. 
Dysmenorrhea  of  the  ovarian  type  is  found.  An  intermen- 
strual PAIN  is  occasionally  present,  recurring  regularly,  midway 
between  the  periods.  There  is  pain  on  defecation,  as  in  the  acute 
form  of  inflammation,  also  in  coitus  or  when  the  body  is  suddenly 
jostled. 

The  reflex  troubles  are  many  and  grave.     Hysteria  is  nearly 


Fiti.  10.'>  — liiverteil  N'ipple      (P'ri)iii  photo  of  author's  en se.) 


OVARIAN    DISEASES.  457 

always  accompanied  by  ovarian  hyperesthesia;  hystero- 
EPiLEPSY  is  present,  the  symptoms  of  which  were  described  in 
discussion  of  ovarian  displacement,  and  sterility  is  common  if 
both  ovaries  are  impaired,  since  the  inflammation  causes  a  sus- 
pension of  their  function. 

DIAGNOSIS.  Sometimes  it  is  hard  to  difTereritiate  between 
the  different  enlargements  of  the  abdomen  and  pelvis.  An  en- 
larged lymphatic  gland,  if  in  the  region  of  the  ovary,  may  give 
rise  to  symptoms  of  ovaritis,  since  there  is  localized  pain  and  a 
tumor  al)out  the  size  and  shape  of  the  ovary.  An  impacted 
bowel  is  often  found  but  should  not  be  r^iiSTAKEN  for  any- 
thing else,  if  care  is  taken. 

In  diagnosing  chronic  ovaritis  keep  in  mind  the  above  men- 
tioned symptoms  which  are  peculiar  to  ovarian  disease.  Also 
remember  the  symptoms  of  chronic  appendicitis,  biliary  and 
renal  calculi,  constipation,  enlarged  lymphatic  glands  and  Fal- 
lopian tube  disease.  The  prognosis  is  favorable  for  a  cure  with- 
out an  operation  unless  it  is  of  a  too  chronic  form  or  there  has 
been  too  much  degeneration.  Too  many  lives  have  been  sacri- 
ficed by  experimental  operations,  the  surgeon  only  supposing 
THERE  WAS  SUCH  A  DISEASE.  By  Osteopathic  treatment  these 
operations  are  avoided  and  the  woman  cured  without  being  un- 
sexed. 

TREATMENT.  The  principal  treatment  is  to  correct 
the  bony  lesions  causing  the  disease.  The  dorsal  vertebrae 
should  be  lined  up,  the  lower  ribs  replaced,  and  uterine  displace- 
ments corrected,  as  the  ovary  will  very  likely  be  congested  and 
inflamed  so  long  as  the  uterus  is  displaced.  Abdominal  treatment 
over  the  ovary,  by  which  the  intestines  are  raised  and  the  broad 
ligaments  straightened  is  helpful,  since  it  partially,  if  not  com- 
pletely, removes  the  obstruction  to  the  return  blood  flow. 


458  DISEASES    OF    WOMEN. 

Rest  is  necessary,  and  the  patient  must  be  kept  off  her  feet- 
as  much  as  possible.  Physicians  often  use  electricity,  counter- 
irritants  and  various  drugs,  both  internally  and  externally,  but 
all  of  these  do  not,  and  will  not,  cure,  since  only  the  symptoms 
can  be  combated  by  their  use.  Ovariotomy,  as  mentioned  be- 
fore, has  become  quite  a  fad.  A  case  of  supposed  ovarian  in- 
flammation, in  which  there  was  no  disease,  was  taken  to  a  noted 
surgeon  who,  after  a  careful  subjective  examination,  pronounced 
it  an  extreme  case  of  ovaritis  and  told  the  patient  that  unless  the 
ovary  was  removed  at  once  she  would  die  of  "rose"  cancer  with- 
in two  years.  Of  course  he  was  mistaken  as  there  was  no  dis- 
ease of  the  ovary,  but  it  illustrates  the  tendency  of  some  surgeons 
to  cut  and  try,  if  an  opportunity  is  given,  in  almost  every  case  of 
ovarian  or  uterine  disorder. 

Ovarian  abscess  follows  many  cases  of  inflammation,  or,  to 
put  it  the  other  way,  inflammation  always  precedes  pus  formation 
in  the  ovary.  I  look  upon  pus  as  decomposed  blood,  or  at  least 
dead  blood  is  necessary  to  pus  formation,  the  cause  of  this  condi- 
tion of  the  blood  being  lack  of  motion.  Moving  blood  is  live 
blood;  stagnant  blood  is  dead  and  the  elements  necessary  to  pus 
formation  are  present.  In  ovarian  abscess  the  blood  has  stag- 
nated in  the  ovary  and  undergone  decomposition,  which  steps 
are  preparatory  to  pus  formation.  The  causes  of  stagnation  of 
the  blood  in  the  ovary  have  been  outlined  under  causes  of  con- 
gestion and  inflammation. 

When  the  pus  at  first  forms  it  becomes  encapsulated;  later 
it  burrows  into  the  peritoneal  cavity  where  it  becomes  circum- 
scribed but  soon  sets  up  a  local  peritonitis  or  escapes  by  burrow- 
ing into  the  vagina.  Sometimes  it  escapes  by  way  of  the  tubes 
into  the  uterus,  but  in  either  case  it  is  discharged  per  vaginam. 
If  of  slow  formation  the  discharge  is  thick,  greenish  yellow  or 


OYARIAX    DISEASES.  459 

brownish  from  presence  of  blood,  and  is  worse  immediately  after 
the  menstrual  period.  If  there  is  free  exit  to  the  pus,  little  is 
absorbed  and  the  toxemia  is  not  marked;  but  if  absorbed,  the 
patient  has  a  cadaverous  appearance  as  a  result  of  the  toxemia. 
In  the  more  marked  cases  irregular  chills  come  on  and  the  patient 
gradually  grows  weaker  and  more  emaciated. 

The  diagnosis,  in  such  cases,  is  based  on  the  character  and 
source  of  the  vaginal  discharge.  In  early  stages  the  usual  symp- 
toms and  signs  of  a  deep  abscess  are  present. 

The  treatment  in  mild  cases  is  one  directed  to  restore  normal 
circulation  through  the  diseased  ovary,  which  can  be  accomplish- 
ed, if  the  pathological  changes  are  not  too  far  advanced,  by  cor- 
recting vaso-motor  disturbances,  replacing  the  uterus  and  ovaries, 
and  securing  good  drainage  by  removing  mechanical  obstruc- 
tions to  the  return  flow  of  the  blood.  In  marked  cases  that  do 
not  yield  to  osteopathic  treatment  the  diseased  ovary  should  be 
removed. 

TUMORS  of  the  ovary  are  usually  of  the  cystic  variety,  but 
an  occasional  solid  tumor,  such  as  a  dermoid  or  fibroid,  is  found. 
Cysts  commonly  arise  from  disturbance  of  the  rupture  of  the 
Graafian  follicles  or  of  the  corpora  lutea.  The  Graafian  follicles 
enlarge  and  rupture,  allowing  their  contents  to  escape  at  each 
menstrual  period.  If,  from  an  inflamed  condition  or  any  other 
cause,  they  do  not  rupture  they  continue  to  swell  rapidly  and 
form  a  cyst.  This  form  is  called  dropsy  of  the  Graafian 
follicle.  The  corpus  luteum  may  swell  and  be  filled  with  a 
yellow  fluid  and  in  this  way  produce  a  cyst.  The  contents  of 
these  cysts  consist  of  a  clear  straw  colored  fluid  which,  in  chronic 
cases,  sometimes  becomes  a  jelly-like  mass  surrounded  by  a  thin 
membrane. 

Dermoid  cysts  are  sometimes  found,  being  somewhat  harder 


460  DISEASES    OF    WOMEN. 

and  composed  of  different  structures,  such  as  hair,  skin,  nails 
and  teeth  which  are  derived  from  the  epiblastic  layer,  and  are  sup- 
posed to  be  the  result  of  invagination  of  this  layer. 

Fibroid  tumors  of  the  ovary  are  occasionally  discovered, 
also  cancers,  but  they  are  rare.  Frequent  congestion  of  the  ovary 
may  result  in  a  deposit  from  which  a  new  growth  appears.  Tu- 
mors are  found  during  the  period  of  sexual  activity,  nullipara 
being  much  more  liable  to  disease  than  multipara,  since  they  do 
not  have  the  physiological  rest  enjoyed  by  the  latter  during 
pregnancy  and  lactation.  By  the  osteopath,  displacements  of 
the  ribs  are  associated  with  ovarian  diseases  and  are  regarded  as 
causes  of  the  formation  of  cysts.  The  lesions  along  the  lower 
dorsal  region  also  weaken  the  ovaries  and  predispose  to  disease. 

SYMPTOMS.  In  cysts  of  the  ovary  the  tumor  is  unnoticed 
until  there  is  some  enlargement  of  the  abdomen.  If  free,  so  that 
it  can  rise  in  the  abdomen,  it  gives  the  woman  the  appearance  of 
l)eing  pregnant.  If  held  down  so  that  it  can  not  rise  it  causes 
pain  in  the  side,  and  in  the  small  of  the  back.  The  weight  of  the 
tumor  causes  a  sense  of  heaviness  and  interferes  with  the  pa- 
tient's gait,  giving  her  the  waddling  gait  of  pregnancy.  Men- 
struation is  painful  and  accompanied  by  an  increase  in  size  of  the 
tumor.  In  some  cases  there  is  scanty  menstruation  or  amenor- 
rhea, making  it  difficult  to  diagnose  the  condition  from  preg- 
nancy. The  pressure  exerted  by  the  tumor  gives  ri.se  to  stomach 
irritation,  edema  of  the  limbs  and  varicose  veins.  Hemorrhoids 
are  usually  found,  resulting  from  pressure  on  the  hemorrhoidal 
plexus  of  veins.  Pain  is  noted  from  pressure  on  or  stretching 
of   the  peritoneum. 

The  growth  of  the  cyst  is  rapid,  while  that  of  the  fibroid  is 
slow.  The  general  health  is  at  first  not  affected,  but  later  is 
gradually  impaired  and  the  vitality  lowered;  there  is  emaciation. 


OVARIAN    DISEASES. 


461 


and  interference  with  the  functions  of  the  different  organs;  the 
face  has  a  careworn,  pinched  expression,  with  the  lines  of  the 
face  deepened.     To  this  condition  the  term  "facies  ovariana" 


Fig.  106. — Ovarian  cyst,  front 
view  (From  i>li<)t<<  of  aullior's 
case.) 


Fig.  107.  —  Ovarian  cyst,  side 
view.  (From  plioto  of  author's 
case.) 


has  been  given.  The  emaciation,  shrunken  cheeks,  hollow  eyes, 
depressed  angles  of  the  mouth  and  distended  nostrils  make  the 
appearance  of  the  patient  characteristic,  if  in  the  latter  stages  of 
the  disease. 

DIAGNOSIS.     The  diagnosis  of  an  ovarian  tumor  is  based 
mostly  on  palpation.     In  order  to  do  this  properly,  the  abdomen 


462  DISEASES   OF   WOMEN. 

should  be  bared  or  the  clothmg  very  much  loosened.  By  care- 
fully laying  on  both  hands  the  spots  of  increased  resistance  can 
be  ascertained.  In  the  early  stages  the  tumor  is  felt  on  one  side 
but  as  it  enlarges  it  pushes  inward  to  the  median  line  and  forms 
a  symmetrical  enlargement.  If  the  tumor  is  of  a  rapid  growing 
variety  of  cyst  it  will  have  an  elastic  feeling  similar  to  that  of  a 
water  bag  filled  with  water. 

Fluctuation  is  an  important  sign  of  a  cyst.  It  is  obtained 
b}"^  fixing  one  side  of  the  tumor  with  one  hand,  then  with  the 
other  giving  a  quick,  stroke  toward  the  opposite  side. 

Percussion  elicits  a  dull  sound  over  the  tumor,  while  the 
surrounding  tissues  give  a  resonant  sound.  By  local  examina- 
tion the  uterus  is  found  pushed  out  of  position  and  crowded 
tightly  down  into  the  pelvis.  The  tumor  may  be  felt  as  a 
GLOBULAR  ELASTIC  mass  to  One  side  of  the  uterus. 

By  the  bimanual  method,  the  size  and  position  of  the 
tumor  can  be  readily  ascertained.  Pregnency  should  be  kept  in 
mind  and  its  characteristic  symptoms  looked  for,  especially  if 
there  is  amenorrhea.  The  writer  recently  saw  a  case  of  this 
kind  in  which  pregnancy  was  mistaken  for  a  cyst.  There  was 
amenorrhea  but  not  the  other  symptoms  of  pregnancy. 

Another  case  came  under  my  notice,  in  which  pregnancy 
complicated  a  cystic  tumor.  On  abdominal  palpation  two  dis- 
tinct bodies  could  be  outlined.  Pregnancy  was  not  diagnosed 
with  certainty  until  fetal  heart  sounds  and  quickening  were  as- 
certained ;  the  early  indications  being  obscured  by  the  tumor. 
The  patient  carried  to  term  and  was  delivered  of  a  well  developed 
mature  child.  In  fact,  the  child  was  not  misshapen  in  the  least, 
molding  not  having  taken  place  since  the  pubic  bones  were  sep- 
arated by  the  enormous  distention.  The  patient's  waist  measure 
was  over  sixtv  inches,  and  the  lower  limbs  were  black  from  the 


OVAKIAN    DISEASES.  463 

numerous  varicosities.  She  was  operated  on  four  months  after 
delivery  and  a  large  multilocular  cyst  somewhat  larger  than  a 
water  bucket,  removed.  The  patient  made  an  uneventful  and 
complete  recovery. 

When  there  is  any  doubt  as  to  the  disease  being  a  cyst  or 
pregnancy  wait  until  the  diagnosis  is  established  before  operat- 
ing, as  was  done  in  the  above  described  case. 

Ascites  can  be  diagnosed  from  a  cyst  by  the  character  of  the 
enlargement,  the  presence  of  some  other  disease,  and  the  percus- 
sion note,  it  being  dull  at  the  edges  and  tympanitic  at  the  center. 

A  uterine  fibroma  is  diagnosed  by  the  consistency  of  the 
tumor  and  the  other  characteristic  symptoms  of  a  fibroid  tumor, 
such  as  hemorrhage  and  the  character  of  the  pain. 

Distention  of  the  uterus  from  retention  of  the  menstrual  flow 
may  be  mistaken  for  a  cyst,  but  the  menstrual  disorders,  moli- 
mina  and  location  of  the  tumor  will  help  to  make  up  the  diag- 
nosis. 

Enlarged  lymphatic  glands  felt  through  the  abdominal  wall 
along  either  side  of  the  spine,  simulate  ovarian  tumors,  but  the 
enlargement  is  gradual  and  the  growth  usually  hard.  A  large 
tumor  is  easily  recognized  but  a  small  one  is  hard  to  diagnose. 
Remember  the  location  of  the  ovarian  cyst,  rapidity  of  growth 
and  the  pressure  symptoms.  Also  remember  that  a  prolapsed 
impacted  bowel  will  form  an  enlargement,  while  a  displaced  rib 
will  give  rise  to  pain  in  the  region  of  the  ovary. 

TREATMENT.  A  great  many  cases  cured  by  osteopathic 
treatment  were  those  in  which  the  former  diagnosis  was  wrong. 
It  is  rare  to  get  a  true  case,  but  common  to  get  one  in  which  there 
is  some  enlargement  of  the  side,  simulating  ovarian  cyst.  The 
bony  lesions  should  be  corrected,  and  whether  it  is  a  cyst  or  not 
the  symptoms  abate  in  most  cases. 


464  DISEASES    OF    WOMEN. 

It  is  not  necessary  to  name  a  disease  in  order  to  treat  it, 
although  a  great  many  physicians  depend  upon  the  name.  The 
osteopath  treats  and  corrects  abnormal  conditions  of  the  anatomy, 
regardless  of  name  or  symptoms  given  it  by  other  physicians. 
If  the  case  is  one  of  true  ovarian  cyst,  as  is  best  evidenced  by  ob- 
taining fluctuation,  treat  it  osteopathically,  that  is  by  correct- 
ing the  lesions  found.  If,  after  a  fair  trial,  the  patient  continues 
to  suffer,  then,  and  not  until  then,  should  recourse  be  made  to 
surgery.  In  addition  to  correcting  bony  lesions  a  loosening  up 
treatment  applied  to  the  spinal  column,  especially  the  low-er  dor- 
sal and  lumbar  regions,  is  very  helpful. 

The  CYST  itself  can  be  directly  manipulated  and  relief  can 
be  given  by  treating  just  above  the  tumor,  lifting  up  and  off  the 
neighboring  structures.  This  abdominal  treatment  is  especially 
indicated  if  there  are  hemorrhoids,  varicose  veins  or  any  pressure 
symptoms. 

Solid  tumors  and  dermoid  cysts  will  only  be  mentioned  since 
they  are  so  rarely  met  with.  Such  diseases  belong  to  surgical 
gynecology  and  removal  is  the  only  rational  treatment.  For 
the  operation  for  removal  of  the  ovary  or  cyst,  reference  should 
be  made  to  some  work  on  surgical  gynecology. 

Cystic  degeneration  of  the  ovary  is  found  in  many  cases  of 
mal-development,  dysmenorrhea  or  chronic  disease  of  the  ovary. 
The  ovary  is  flattened,  elongated,  softened  and  covered  with 
localized  patches  of  a  yellowish  color,  these  patches  being  areas 
of  degeneration;  the  uterus  is  small,  soft  and  usually  anteflexed. 

The  cause  is  not  well  understood.  Most  of  the  cases  treated 
by  the  writer  were  chronic,  the  trouble  dating  back  to  pu- 
berty, so  it  seems  that  poor  development  is  one  of  the  important 
causes.  Displacements,  both  uterine  and  ovarian,  were  found 
in  some,  and  in  all  marked  cases,  an  anterior  or  flattened  condi 


OVARIAN    DISEASES.  465 

tion  of  the  ninth,  tenth,  eleventh  or  twelfth  thoracic  vertebrae. 
This  condition  disturbs  the  nutrition  of  the  ovary  and,  if  present 
before  puberty,  the  ovary  fails  to  develop  properly,  hence  the 
infantile  and  cystic  types. 

The  indications  of  a  cystic  degeneration  of  the  ovary  are, 
dysmenorrhea  of  the  worst  form,  usually  a  muddy  complexion 
with  ERUPTIONS  and  a  general  run  down,  nervous,  mal-nour- 
ISHED  condition.  Local  examination  is  often  negative,  the  physi- 
cian not  being  able  to  outline  the  ovary.  In  others  it  can  be  felt 
as  a  flattened,  elongated  body  somewhat  tender  to  the  touch. 
The  uterus  feels  as  if  it  were  covered  by  a  thin  layer  of  soft 
tissue  and  there  is  a  peculiar  slimy  condition  of  the  vaginal  walls, 
with  leucorrhea  present  in  a  very  bad  form.  Headache,  indi- 
gestion, NERVOUSNESS  and  hysteria  are  common  symptoms  and 
the  patient  presents  the  appearance  of  a  chronic  toxemia  with  its 
pasty  complexion. 

The  treatment  consists  of  correction  of  the  vertebral  lesions. 
Sometimes  this  can  be  done  and  a  cure  follows,  but  in  very  chronic 
cases  it  is  difficult  and  an  operation  for  the  removal  of  the  ovaries 
is  indicated,  after  treatment  has  been  given  a  fair  trial  and  the 
patient  not  benefited. 

Ovariotomy  is  often  followed  by  a  peculiar  drawing  or 
PULLING  sensation,  referred  to  the  lower  part  of  the  abdomen, 
caused  by  the  formation  and  contraction  of  the  scar  tissue.  Brandt 
advises  massage  in  such  cases.  In  some  cases  treated  by  the 
writer,  especially  those  in  which  hysterectomy  had  also  been  per- 
formed, STRETCHING  THE  SCAR  tissue  and  BREAKING  up  the  ad- 
hesions  by  bimanual  manipulation  proved  curative. 


466  DISEASES    OF    WOMEN. 


REFLEX  DISORDERS. 


THE  UTERINE  and  ovarian  reflexes  constitute  one  of  the 
most  interesting  subjects  associated  with  the  diseases  of  women. 
They  are  so  varied  and  affect  so  many  organs  that  I  always  sus- 
pect the  uterus  or  ovaries  to  be  in  a  disordered  condition  if  I  have 
a  case  in  which  the  symptoms  are  unusual  or  peculiar,  or  which 
does  not  yield  to  the  ordinary  spinal  treatment.  The  pelvic  or- 
gans may  not  be  at  fault,  but  as  a  rule,  in  unusual  cases,  they  are. 

The  NERVOUS  CONNECTIONS  between  the  ovaries,  uterus  and 
vagina,  with  the  splanchnic  nerves  and  with  the  spinal  cord  in  the 
lumbar  and  sacral  regions,  through  the  hypogastric  and  other 
sympathetic  plexuses,  anatomically  explain  many  of  the  re- 
flexes and  pains  which  accompany  uterine  and  ovarian  diseases. 
These  reflexes  are  not  confined  to  the  immediate  nerves  but  are 
found  in  distant  nerves  in  various  parts  of  the  body.  The  head, 
eyes,  throat  or  limbs  may  be  affected  as  frequently  as  some  vis- 
cus  that  is  near. 

All  organic  life  is  run  by  the  sympathetic  system.  This 
system,  like  a  chain,  is  as  strong  as  its  weakest  point.  An  ab- 
normal irritation  at  one  part  will  give  rise  to  an  impulse  that  will 
be  transmitted  over  the  entire  system  and  if  every  part  is  work- 
ing properly  little  injury  follows,  but  if  one  part  is  weakened,  it 
is  not  strong  enough  to  stand  the  increased  stimulation  or  shock 
and  is  affected  by  it.  A  lacerated  cervix,  in  a  strong,  healthy 
woman,  does  not  produce  any  appreciable  secondary  symp- 
toms for  several  years,  but  if  such  an  accident  occur  in  a  patient 
already  weakened,  the  effects  are  immediate.  There  is  nerve 
loss  in  both.  One  can  bear  it  without  symptoms,  the  other  can- 
not. 


REFLEX    DISORDERS.  467 

Lesions  weakening  the  parts  innervated  from  that  region  are 
the  predisposing  causes  of  reflexes.  If  a  lesion  is  found  at  the 
fourth  dorsal  which  weakens  the  heart,  any  uterine  displace- 
ment would  be  an  exciting  cause  and  would  reflexly  affect  the 
heart.  Loss  of  nerve  force  affects  the  weakest  part  in  a  similar 
way,  that  is,  it  increases  the  weakness  of  the  organ. 

The  uterus  and  ovaries  are,  or  should  be,  the  strongest 
LINKS  of  a  woman's  health  in  mind  and  body.  Diseases  impair- 
ing them  will  certainly  be  followed  by  general  weakness  and  re- 
flexes. However,  the  uterine  disease  is  not  always  primary  but 
frequently  results  from  a  general  starved  condition  of  the  entire 
body. 

HEADACHE  in  the  top  of  the  head  or  in  the  suboccipital  re- 
gion is  characteristic  of  uterine  disease,  of  which  metritis  or  en- 
dometritis is  the  most  common.  The  patient  describes  the 
headache  as  a  dull,  heavy  pain  or  localized  burning  sensation  in 
the  top  of  the  head.  In  some  cases  there  is  tenderness  of  the 
scalp,  in  others,  the  pain  or  ache  is  internal.  If  in  the  neck  or 
suboccipital  region  there  is  a  dull,  constant  ache  with  tendency 
to  retraction  of  the  head. 

Uterine  displacements,  fibroid  tumors,  menstrual  disorders, 
INFLAMMATION  and  CONGESTION  of  the  utcrus,  all  produce  this 
form  of  headache,  the  two  latter  causes  being  the  most  common. 
In  some  cases,  the  headache  is  constant,  in  others  intermittent, 
while  the  approach  of  menstruation  or  being  on  the  feet  more 
than  usual,  increases  the  pain. 

The  ACHE  in  the  back  of  the  neck  and  head  is  partly  due 
to  a  slipped  atlas  or  axis  impinging  on  the  suboccipital  nerves, 
then  the  exciting  cause,  or  uterine  disease,  increases  the  weak- 
ness and  pain.  The  aclie  in  the  top  of  the  head,  is  supposed  to 
be  due  to  some  disorder  of  the  ganglion  ribes,  resulting  from  a. 


468  DISEASES   OF   WOMEN. 

disturbance  of  the  lower  extremity  of  the  chain,  the  gangUon  im- 
par.  In  such  cases  treatment  applied  to  the  neck  frequently 
increases  the  pain,  and  even  in  the  most  favorable  cases  only 
stops  it  temporarily. 

Treatment  should  be  applied  to  the  lower  lumbar  region, 
there  relaxing  contractured  muscles  and  relieving  the  tension 
exerted  by  some  displacement  which  is  usually  very  slight.  Many 
osteopaths  have  reported  to  me  that  inhibition  at  the  second 
LUMBAR  SPINE  would  relieve  the  uterine  type  of  headache.  Per- 
sonally, I  seldom  employ  such  means,  but  endeavor  if  possible 
to  give  a  corrective,  rather  than  a  palliative,  treatment.  If  this 
does  not  relieve,  recourse  should  be  made  to  a  local  treatment 
which  seldom  fails  to  relieve.  The  writer  has  cured  the  worst 
forms  of  uterine  headaches,  after  all  other  methods  had  failed, 
by  simply  lifting  up  the  uterus  by  pressure  on  the  cer- 
vix or  completely  replacing  it  if  possible.  To  permanently 
cure  these  headaches  treatment  should  be  directed  to  correct 
the  uterine  troubles. 

In  the  male  there  is  a  similar  headache  coming  from  an  en- 
larged or  diseased  prostate  gland.  In  such  cases  the  patient 
complains  of  a  dull,  burning  pain  in  the  top  of  the  head,  tinnitus 
aurium  and  loss  of  memory.  On  rectal  examination,  if  the  pa- 
tient is  above  the  age  of  thirty  or  has  indulged  in  sexual  excesses, 
the  prostate  gland  will  be  found  congested  and  tender. 

Migraine,  also  called  hemicrania,  is  a  form  of  headache  affect- 
ing one  lateral  half  of  the  head  and  is  traceable,  in  a  great  many 
cases,  to  uterine  disease.  Endometritis  is  the  most  common 
form  producing  it.  Usually  there  is  an  extreme  pain  and  vaso-mc- 
tor  dilatation  with  increased  blood  pressure  which,  in  most  cases, 
lasts  several  days.  In  some  there  is  a  non-developed  uterus 
in  others  a  displacement.     The  pain  is  worse  near  the  monthly 


REFLEX    DISORDERS.  469 

period;  also  most  of  these  headaches  stop  at  the  menopause  which 
indicates  that  the  menstrual  function  is  partly  to  blame. 

Frontal  headaches  accompany  gastric  disturbances,  bil- 
LiousNESs,  INDIGESTION  and  dietetic  errors  often  produce  it. 
The  ingestion  of  ice  water  often  produces  pain  in  the  frontal  area. 
McGillicuddy  says  Lender  Brunton  finds  that  "constipation  and 
presumably  intestinal  irritation  cause  a  diffuse  frontal  head- 
ache over  the  whole  brow.  When  there  is  not  constipation  and 
the  condition  is  one  of  gastric  irritation  the  pain  is  either  just 
above  the  eyes  (when  it  will  be  relieved  by  acids)  or  just  at  the 
roots  of  the  hair  when  it  will  be  relieved  by  alkalis."  This  is  of 
interest  to  us  in  that  it  in  a  measure  corroborates  our  experience. 
As  to  the  condition  of  the  stomach,  or  rather  as  to  whether  acids 
or  alkalis  relieve  it,  it  is  important  to  remember  that  headache 
above  the  eyes  suggests  an  alkaline  condition  of  the  stomach;  at 
roots  of  hair,  an  acid  condition.  This  condition  of  the  stomach 
can  be  changed  by  treatment  applied  to  the  middle  thoracic  area, 
the  fifth  thoracic  vertebra  being  the  best  place. 

STOMACH  DISORDERS  are  frequently  reflex  from  uterine 
or  ovarian  disease  or  pregnancy.  Nausea  and  vomiting  in  preg- 
nancy is  a  well  known  example  which  illustrates  the  sympathy 
between  the  two.  However,  the  better  the  condition,  other  things 
being  equal,  the  less  the  amount  of  stomach  derangement.  If  the 
stomach  is  in  a  perfectly  normal  condition  I  doubt  that  nausea  and 
vomiting  would  occur.  If  the  stomach  is  weakened  by  abuse 
or  lesions,  coitus,  uterine  displacements  or  even  the  odor  of  cook- 
ing food  produces  nausea  or  intensifies  it  when  once  started.  The 
best  immediate  treatment  for  nausea,  one  that  covers  a  larger 
per  cent  of  cases  than  any  other,  is  replacement  of  the  uterus. 
It  has  usually  settled  down  in  the  pelvis,  that  is,  slightly  pro- 
lapsed or  the  anteflexion  is  exaggerated. 


470  DISEASES    OF    WOMEN. 

Another  illustration  of  reflex  disturbances,  principally  nausea 
and  vomiting,  is  found  in  cases  in  which  the  os  uteri  is  rapidly 
dilated.  In  some  the  vomiting  is  violent  and  lasts  for  several 
hours.  During  labor  the  patient  often  vomits,  this  being  due, 
possibly,  to  pressure  exerted  on  the  cervix  in  dilatation  of  the  os. 
There  is  a  close  sympathy  between  the  stomach  and  the  other 
abdominal  and  the  pelvic  organs.  Pressure  on  the  kidney, 
ovary  or  testicle  produces  a  nauseating  effect. 

The  NERVE  SUPPLY  of  the  uterus  is  closely  connected  with 
that  of  the  other  viscera,  especially  the  stomach,  through  the 
splanchnic  nerves.  Since  the  stomach,  in  this  day  and  age  of 
the  world,  is  one  of  the  most  abused  organs  and  one  very 
largely  diseased,  it  follows  that  it  may  readily  be  affected  reflexly, 
the  weakest  organ  being  affected  first. 

Gastralgia  accompanies  a  recent,  or  sudden  displacement  of 
the  uterus,  pain  being  localized  over  the  stomach  with  con- 
traction of  the  abdominal  muscles.  It  is  also  found  in  ovarian 
colic  and  other  forms  of  painful  menstruation.  Distention  of 
the  stomach  with  gas  accompanies  the  menstrual  epoch,  and  may 
be  so  severe  that  the  heart's  action  is  embarrassed  by  it.  "Faint- 
ness,  boulimia  and  anorexia  are  frequently  the  result  of  uterine 
or  ovarian  congestion."  Gastralgia  frequently  occurs  at  the 
onset  of  menstruation.  Morbid  craving  with  chlorosis  occur  at 
puberty  in  certain  classes  of  girls. 

In  cases  of  emesis  due  to  a  diseased  or  displaced  uterus,  or- 
dinary treatments  are  seldom  effectual,  the  patient  being  re- 
lieved only  by  replacement  of  the  uterus.  An  opiate,  or  even 
chloroform,  has  little  effect  in  these  cases  since  the  sympathetic 
system  is  irritated. 

A  DISPLACED  OVARY  is  a  common  cause  of  nausea  aside  from 
pregnancy.     The  patient  describes  it  as  a  "very  sick"  sensation 


REFLEX    DISORDERS.  471 

in  which  she  is  ''sick  all  over."  In  sudden  uterine  displace- 
ment, I  believe  the  nausea  to  be  due  more  to  the  ovarian  dis- 
turbance which  necessarily  complicates,  than  to  the  uterine.  If 
inflammation  is  present  as  a  complication  of  the  displacement 
nausea  follows  in  a  large  per  cent,  of  chronic  as  well  as  acute  cases, 
and  is  made  worse  by  anything  increasing  the  amount  of  con- 
gestion or  degree  of  displacement. 

Chronic  dyspepsia  is  sometimes  traceable  to  uterine  disease, 
in  that  it  affects  nutrition,  thus  weakening  all  the  organs  of  the 
body. 

PHARYNGEAL  REFLEXES  are  common.  The  patient  com- 
plains of  something  in  the  throat  and  is  unable,  or  thinks  she  is 
unable  to  swallow.  The  writer  recalls  a  case  of  laceration  of  the 
cervix  uteri  in  which  the  throat  was  reflexly  affected.  Con- 
traction of  the  throat  muscles  would  begin  just  as  soon  as  the  pa- 
tient attempted  to  eat  and  would  prevent  her  sw^allowing.  In 
other  cases  there  w^as  found  a  sore  throat  or  redness  of  the  fauces 
with  no  particular  inflammation. 

The  tonsils  frequently  enlarge  during  menstruation  and  are 
usually  diseased  in  chronic  uterine  trouble.  This  is  found  par- 
ticularly in  rheumatic  cases  in  which  there  is  retention  of  the 
menstrual  flow  as  the  cause.  Some  gynecologists  claim  that 
uterine  diseases  are  manifested  by  changes  in  the  throat  so  mark- 
ed and  constant  that  the  uterine  disturbance  can  be  diagnosed 
by  them.  This  is  true  in  some  cases  of  catarrhal  disease  of  the 
uterus.  Redness  of  the  fauces  and  chronic  disease  of  the  ton- 
sils are  at  least  suggestive  of  uterine  disease. 

Laryngeal  affections  from  uterine  diseases  are  best  repre- 
sented by  a  chronic,  unsatisfactory,  hacking  cough  which  be- 
comes exaggerated  at  the  menstrual  periods  and  even  produces 
soreness  of  the  abdomen  from  the  frequent  straining  and  con- 


472  DISEASES    OF    WOMEN. 

traction.  The  voice  is  sometimes  affected  and  it  is  a  well  known 
fact  that  singers  frequently  have  to  cancel  engagements  on  ac- 
count of  the  changes  in  the  voice. 

In  VENEREAL  diseases,  especially  syphilis,  the  throat  and 
voice  are  affected,  the  voice  becoming  harsh  and  husky.  In  the 
above  mentioned  cases,  lesions  of  the  neck  are  predisposing 
causes  and  should  receive  treatment,  while  the  uterine  trouble 
is  the  exciting  cause. 

CEREBRAL  NEUROSIS  in  the  form  of  melancholia,  mor- 
bid fears,  insomnia  and  irritability  are  often  met  with  in  cases  of 
chronic  uterine  disease.  Some  are  due  to  loss  of  nerve  energy, 
others  to  brooding  over  a  supposed  or  real  disease.  There  is  a 
class  of  patients  who  have  ''uterus  on  the  brain."  They  are 
constantly  talking  about  it,  treating  it  and  thinking  about  it  so 
much  that  in  time  probably  some  disease  does  arise.  These  are 
the  kind  which  are  cured  by  some  new  remedy,  or  in  which  won- 
derful cures  have  been  made.  Another  type  embraces  those 
who  get  the  "blues,"  in  which  there  is  mental  depression,  loss 
of  memory,  irritability,  or  perhaps  lethargy.  In  the  last  men- 
tioned effect  the  patient  complains  of  being  "no  account,"  al- 
ways tired  and  suffers  with  morbid  fears. 

A  similar  condition  is  found  in  the  male.  Tell  a  man  that 
he  is  impotent  and  he  becomes  afraid  of  himself.  He  imagines 
that  every  little  pain  comes  from  that,  and  becomes  despondent, 
melancholic  and  in  a  great  many  cases,  suicide  is  the  outcome. 
The  influence  of  the  mind  on  the  pelvic  organs  is  very  mark- 
ed, and  in  cases  in  which  there  is  only  imaginary  disease,  sug- 
gestive therapeutics  has  been  used  successfully. 

Insanity  has  followed  uterine  disease  in  many  cases.  Re- 
cently there  was  brought  to  the  A.  T.  Still  Infirmary  a  case  of 
insanity,  following  too  frequent  childbearing.     The  patient 


REFLEX    DISORDERS.  473 

was  treated  and  cured  by  correcting  an  axis  lesion,  the  predis- 
posing cause.  This,  with  the  excessive  strain  on  the  nervous 
system,  unbalanced  her  mind.  She  had  been  pregnant  four  times 
in  three  years;  in  two  the  fetuses  were  carried  to  term,  in  the 
other  two  she  aborted. 

The  writer  was  called  in  consultation  in  a  case  of  the  melan- 
cholic type  of  insanity  in  which  there  was  a  history  of  criminal 
abortion,  the  patient  thinking  that  punishment  was  being  sent 
upon  her  for  her  crime.  She  brooded  over  her  condition  and 
went  from  bad  to  worse  until  she  finally  died  from  malnutrition. 

Another  case  of  insanity  from  ovarian  disease  came  under 
my  notice.  The  ovaries  degenerated  and  covered  with  yellowish 
patches,  it  being  a  case  of  cystic  degeneration.  Ovariotomy  was 
performed  as  a  last  resort  but  the  patient  was  not  benefited.  In 
cases  of  insanity  of  these  sorts,  the  cervical  lesions  are  about  as 
important  as  the  pelvic  disturbances. 

Insomnia  is  due  to  increased  activity  of  the  brain,  in  which 
there  is  hyperemia,  usually  of  the  active  form.  Many  cases  are 
the  direct  resvilt  of  uterine  disease  of  some  form,  which  keeps  the 
sympathetic  system  in  a  stimulated  condition.  Many  patients 
awake  at  a  certain  hour  and  can  not  go  back  to  sleep.  In  such 
cases  the  heart  is  stimulated  by  the  irritation  to  the  sympa- 
thetic gangliated  cord,  it  beats  harder  and  more  rapidly,  forcing 
more  blood  into  the  brain,  thus  keeping  it  active. 

HICCOUGH  or  "kicking  of  the  diaphragm"  is  usually 
hysterical  but  may  follow  pelvic  irritation.  A  case  of  endome- 
tritis accompanied  by  hiccough  came  under  my  notice,  and  as 
soon  as  the  uterine  trouble  was  relieved  the  hiccoughing  ceased, 
although  there  was  a  bony  lesion  at  the  fifth  cervical  which  weak- 
ened the  phrenic  nerve.  The  hiccough  recurred  from  time  to 
time  until  the  cervical  lesion  was  corrected. 


474  DISEASES   OF   WOMEN. 

Spasmodic  contractions  of  the  diaphragm  are  in  most  cases 
due  to  uterine  displacements.  I  recently  saw  a  case  in  which 
the  diaphragm  and  the  abdominal  muscles  would  contract  every 
few  seconds,  markedly  interfering  with  respiration.  After  giving  the 
ordinary  treatments  to  reach  the  phrenic  nerve  and  having  failed 
to  stop  the  spasm,  a  local  examination  was  made  and  a  retro- 
flexion of  the  uterus  found.  As  soon  as  this  was  corrected  the 
spasms  ceased,  only  to  recur  when  the  uterus  was  again  dis- 
placed. Since  the  uterus  would  not  stay  in  the  proper  position 
and  the  spasm  recurred  as  soon  as  the  uterus  was  displaced,  a 
tampon  was  placed  in  the  posterior  fornix  to  hold  it  in  place, 
this  entirely  relieving  the  patient. 

In  ordinary  cases  of  hiccough  inhibition  of  the  phrenic  nerve, 
either  at  its  origin  or  along  its  course,  holding  the  breath  or  drink- 
ing cold  water,  is  usually  sufficient  to  stop  the  attack. 

THE  CARDIAC  reflexes  are  very  common  and  important, 
and  are  indicated  by  palpitation,  irregularity,  too  slow  or  too 
rapid  pulse,  pain  in  the  heart,  or  "sinking  spells,"  the  patient 
being  unable  to  breathe  while  lying  down.  I  have  seen  cases 
in  which  the  heart  would  commence  to  rapidly  palpitate,  this 
lasting  for  several  minutes,  then  ceasing  as  suddenly  as  it  began. 
The  most  remarkable  case  of  palpitation  which  ever  came  under 
my  care  was  one  in  which  the  pulse  rate  was  so  rapid  that  it  was 
impossible  to  accurately  estimate  it,  these  attacks  coming  on 
when  the  uterus  became  displaced.  The  uterus  was  not  held 
firmly  in  position  and  a  little  strain,  running,  or  even  standing 
for  a  longer  period  than  usual  would  bring  on  a  displacement. 
Just  as  soon  as  the  uterus  prolapsed,  it  seemed  to  stimulate  sym- 
pathetic nerve  force,  and  in  this  case  the  heart  was  affected  in 
preference  to  other  viscera  because  of  lesions  of  the  fourth  and 
fifth  ribs  on  the  left  side.     The  attacks  could  be  checked  by  re- 


KEFLEX    DISORDERS.  476 

placing  the  uterus  but  the  patient  was  not  cured  until  the  ribs 
lesions  were  corrected. 

Another  form  of  cardiac  reflex  is  the  weak  or  irritable  heart 
which  is  best  represented  m  patients  who  have  "sinking  spells." 
The  patient  becomes  unconscious,  the  pulse  very  weak,  in  some 
cases  can  not  be  detected,  and  she  has  all  the  sj'mptoms  of  ap- 
proaching death.  In  such  cases  first  raise  the  ribs  over  the 
heart.  If  that  does  not  relieve  give  a  local  treatment,  lifting  up 
the  uterus,  and  the  effect  will  be  immediate. 

In  all  those  functional  heart  affections,  there  is  some 
bonj^  lesion,  usually  at  the  fourth  or  fifth  dorsal  vertebra  or  cor- 
responding ribs  on  the  left  side  which  either  disturb  the  innerva- 
tion or  press  directly  on  the  heart. 

Pain  in  the  heart,  as  in  true  or  false  angina  pectoris,  is  the 
most  distressing  cardiac  reflex,  giving  the  patient  the  feeling  of 
imminent  death.  The  pain  is  referred  to  the  precordial  re- 
gion, back  and  arm.  In  the  mild  forms  the  attacks  last  but  a 
few  moments  and  the  pain  is  described  as  a" stitch"  in  the  region 
of  the  heart.  Accompanjdng  this  is  a  sense  of  suffocation,  the 
patient  struggles  for  her  breath;  the  left  hand  and  arm  become 
numb,  and  in  some  cases  cold  and  rigid.  These  symptoms  are 
reflex  and  are  explained  by  the  fact  that  the  same  segment  of 
the  cord  that  supplies  the  arm  supplies  the  heart.  The  suffocat- 
ing feeling  is  due  to  lessened  activity  of  the  heart,  which  follows 
an  improper  oxygenation  of  the  blood.  This  condition  in  many 
cases  follows  a  disturbance  of  the  nerve  force  to  the  heart,  the 
result  of  a  bony  lesion  plus  pelvic  irritation. 

THE  INTESTINAL  REFLEXES  which  accompany  uterine 
diseases  are  enteralgia,  diarrhea  and  a  catarrhal  condition  in 
which  mucus  is  discharged.  In  most  cases  a  mild  form  of  diar- 
rhea accompanies  normal  menstruation,  as  a  result  of  the  general 


476  DISEASES    OF    WOMEN. 

congestion  of  the  pelvic  organs.  This  congestion  reaches  the 
bowel  and  from  it  results  a  hypersecretion,  causing  the  increased 
irritation.  This  also  occurs  in  certain  forms  of  uterine  displace- 
ments, usually  backward,  pressing  on  the  bowel  and  stimulating 
instead  of  inhibiting  it.  This  is  not  properly  a  reflex  condition 
since  the  organs  are  in  apposition. 

Cramping  of  the  intestines  occurs  in  ovarian  diseases,  es- 
pecially congestion  of  the  ovary.  It  seems  to  be  reflected  over 
the  entire  abdomen  with  the  pain  localized  around  the  umbili- 
cus, in  fact  patients  often  say  they  are  suffering  with  stomach 
ache. 

Mucous  SHREDS  or  patches  are  often  discharged  from  the 
bowels  in  cases  of  chronic  uterine  disease.  They  have  the  ap- 
pearance of  a  leucorrheal  discharge  and  probably  depend  upon 
the  same  causes  that  produce  leucorrhea.  In  hystero-epileptic 
patients,  this  discharge  is  greatly  increased  just  prior  to  the  at- 
tack. 

GLANDULAR  REFLEXES  are  most  marked  in  the  mammary 
glands,  they  being  so  intimately  associated  with  the  generative 
organs.  During  menstruation  they  become  tender  and  congested, 
and  in  pregnancy  begin  to  change  in  color  and  size.  For  a  week 
or  more  after  labor,  nursing  of  the  baby  brings  on  after  pains  by 
causing  uterine  contraction.  In  cases  of  threatened  post  partum 
hemorrhage  it  is  advisable  to  permit  the  baby  to  nurse  soon  after 
delivery,  encouraging,  or  probably  causing,  uterine  contraction. 

In  most  cases  of  mastitis  the  trouble  lies  in  the  uterus. 
In  many  cases  seen  and  treated  by  the  writer  this  could  be  proven. 
If  the  lochial  discharge  were  stopped  the  mammae  became  ten- 
der, but  became  normal  if  further  uterine  trouble  were  prevented, 
their  condition  varying  with  the  changes  in  the  uterine 
condition. 


REFLEX    DISORDERS.  '  477 

In  polypi  of  the  uterus  they  are  frequently  reflexly  affected 
in  that  they  become  tender,  engorged  and  in  some  cases  secrete 
a  fluid  similar  to  milk.  In  many  cases  of  displacement  of  the 
UTERUS  some  activity  of  the  mammary  glands  can  be  noted. 
The  wTiter  has  seen  cases  of  uterine  displacement  in  which  drops 
of  milk  came  from  the  nipple  whenever  the  gland  was  squeezed. 
Flexions  were  most  frequently  the  only  causes  to  which  the 
phenomenon  could  be  attributed. 

At  the  menopause,  tingling  sensations  or  even  pains  occur 
in  the  glands.  As  menjtioned  under  ovarian  diseases,  inversion 
of  the  nipple  is  indicative  of  ovarian  disease  on  the  same  side. 
Lumps  often  form  in  the  breast  as  a  result  of  reflex  irritation  from 
uterine  disease.  In  others,  a  condition  of  mastodynia  is  found. 
In  cases  of  the  formation  of  lumps  the  physician  usually  diag- 
noses the  case  as  one  of  cancer  of  the  breast  and  advises  removal. 

In  some  the  breasts  atrophy,  in  others  they  hypertrophy. 
As  stated  before,  the  size  of  the  breast  is  determined  by  the  degree 
of  activity  of  the  sexual  organs,  the  ovaries  having  the  most  to 
do  with  it. 

The  thyroid  gland,  the  function  of  which  is  yet  unknown, 
enlarges  at  the  menstrual  period  and  during  pregnancy.  Cer- 
tain forms  of  goitre  are,  I  think,  due  in  many  cases  to  uterine 
diseases  as  an  exciting  cause  while  the  predisposing  cause  is  a 
displaced  first  rib,  or  a  lesion  of  the  lower  cervical  vertebrae  or 
clavicle.  It  is  exceedingly  rare  to  find  a  case  of  true  goitre  in  the 
male,  and  this  alone  is  suggestive  of  some  close  connection  be- 
tween the  gland  and  the  sexual  organs. 

"  Whenever  there  is  a  persistent  irritation  involving  the 
uterine  muscles,  it  will  cause  a  persistent  swelling  of  the  thyroid." 
The  globus  hystericus  is  more  common  at  the  menstrual  time. 
This  is  the  result  of  the  enlargement  thus  causing  a  narrowing 


478  ■  DISEASES    OF    WOMEN. 

OF  THE  canal,  which  produces  the  sensation  of  a  knot  in  the  throat. 
Reed  says  "women  with  goitre  generally  suffer  with  menorrha- 
gia  and  metrorrhagia;  extirpation  of  the  thyroid  is  followed  by 
general  atrophy.  Myxedema  in  women  is  generally  associated 
with  amenorrhea.  In  Cretins,  there  is  a  diminution  and  often 
an  entire  loss  of  sexual  power.  Menstrual  symptoms  are  among 
the  foremost  symptoms  of  exophthalmic  goitre." 

Ptyalism,  or  increased  secretion  of  saliva,  is  one  of  the  early 
symptoms  of  pregnancy  and  is  also  found  associated  with  men- 
struation. Often  the  parotid  glands  enlarge  at  this  time.  The 
writer  had  a  case  in  which  the  salivary  glands  enlarged  soon  after 
the  patient  gave  birth  to  a  child.  At  a  second  pregnancy  the 
swelling  disappeared  but  immediately  after  confinement  they  be- 
came enlarged  a  second  time. 

As  mentioned  before,  the  tonsils  are  sometimes  reflexly  dis- 
eased as  a  result  of  uterine  displacement.  Women  subject  to 
tonsillitis  usually  have  ovarian  disease.  In  some  cases  the  ton- 
sils become  hard  and  tender  at  periodic  intervals  corresponding 
to  the  menstrual  periods.  Parotitis  often  descends  to  the  ovary, 
producing  a  severe  ovaritis. 

The  sweat  glands  are  also  frequently  diseased  as  a  result  of 
uterine  trouble,  but  if  inactive,  are  more  often  the  cause  of 
uterine  disturbances.  Excessive  perspiration  is  found  in  some 
patients.  In  others  the  odor  is  very  marked  and  offensive,  es- 
pecially that  from  the  axillary  glands.  In  many  cases  a  local- 
ized perspiration  takes  place,  sometimes  a  lateral  half  of  the  face 
being  bathed  in  sweat  while  the  opposite  side  is  perfectly  dry. 
Such  a  condition  is  called  hemidrosis.  Cervical  lesions  were 
present  in  all  such  cases  treated  by  the  writer.     Rheumatism  and 

RHEUMATOID    ARTHRITIS   folloW   the   RETENTION    of     thc    menStTUal 

flow  if  the  sweat  glands  are  inactive.     The  skin  is  harsh  and  dry 


REFLEX    DISORDERS.  479 

and  does  not  excrete  the  poisonous  elements  arising  from  re- 
tention of  the  menses,  hence  they  remain  in  the  blood  and  give 
rise  to  symptoms  closely  resembling  rheumatism. 

HYPERESTHESIA  accompanies  pelvic  disease  in  many 
cases.  In  these  cases  the  spine  is  irritable  and  the  least  cutane- 
ous stimulation  produces  a  marked  contraction  or  even  a  spasm 
of  the  muscles  of  the  body.  A  light  touch  is  productive  of  a 
greater  reflex  than  quite  a  heavy  presssure.  In  some  there  are 
shooting  pains  in  different  parts  of  the  body,  especially  in  the  in- 
tercostal nerves,  which  come  and  go,  remaining  only  an  instant. 
In  others  the  pain  is  referred  only  to  the  spinal  column  and 
the  least  irritation  excites  rigid  contractions.  In  most  of  the 
cases  I  have  examined  uterine  trouble  was  found.  A  displace- 
ment, usually  backward  with  a  metritis,  is  the  most  comnion 
cause  producing  it.  These  troubles  can  be  traced  back  to  a  hard 
fall  or  sudden  jar  of  the  body  which  produced  the  uterine  dis- 
placement, this  in  turn  affecting  the  ovaries  and  causing  hyper- 
esthesia of  them. 

In  some  cases  there  is  a  congestion  of  the  spinal  cord  and 
MENINGES,  which  keeps  the  nerve  cells  and  nerves,  especially  the 
sensory  nerves,  in  a  state  of  irritation.  The  supraspinous  lig- 
aments are  softened  and  thickened  as  a  result  of  the  increased 
"vascularity  and  seem  to  be  readily  compressed  on  palpation,  this 
giving  a  sort  of  crepitus-like  feeling  or  sensation.  Spinal  irrita- 
tion is  a  very  common  accompaniment  of  hysteria,  the  tender 
spots  often  changing  from  time  to  time  and  from  place  to  place. 

The  treatment  in  such  cases  must  be  a  very  gentle  and  mild 
spinal  treatment  by  which  the  hyperesthesia  is  gradually  work- 
ed out  as  the  nerves  become  better  nourished  and  the  circula- 
tion improves.  Bony  lesions  along  the  spinal  column  indicate  the 
points  at  which  the  irritation  is  greatest.     These  should  be  care- 


480  DISEASES    OF    WOMEN. 

fully  treated  and  finally  corrected,  this  being  a  preliminary  step 
to  the  correction  of  the  uterine  disease  or  displacement.  A  hard 
SPINAL  TREATMENT  in  such  cases  invariably  brings  on  the  men- 
strual FLOW.  Local,  treatment  should  be  given  occasionally 
if  there  is  a  displacement,  if  the  uterus  does  not  remain  in  posi- 
tion after  it  has  once  been  replaced.  The  inflammation  should 
be  treated  and  the  pelvic  circulation  regulated. 

The  prognosis  is  unfavorable  for  a  rapid  cure  since  it  takes 
time  to  overcome  the  general  run-down  condition  of  the  system, 
but  in  time  a  majority  of  these  cases  can  be  cured.  Patients 
have  come  to  the  A.  T.  Still  Infirmary  that  had  been  given 
all  the  ordinary  treatments  for  this  condition,  without  any  help. 
By  correcting  the  bony  lesions  interfering  with  the  pelvic  circu- 
lation, these  cases  have  been  cured,  which  goes  to  prove  that  the 
bony  lesions  were  the  real  cause  of  the  hyperesthesia. 

This  condition  frequently  follows  typhoid  fever  as  a  result 
of  the  severe  muscular  contractions  which  have  pulled  the  ribs 
and  vertebrae  slightly  out  of  place.  Some  cases  are  due  to  an 
interference  with  the  circulation  of  the  spinal  cord,  and  in 
these  as  in  most  other  cases,  the  spinal  column  should  receive  the 
principal  treatment,  which  consists  of  adjustment  of  its  various 
component  vertebrae. 

COLD  FEET  and  hands  indicate  poor  circulation  in  those 
parts.  In  some  female  diseases  the  coldness  of  the  extremities 
is  very  marked,  the  hands  being  cold  even  on  warm  days.  The 
circulation  through  the  pelvic  organs  is  retarded,  affecting 
the  blood  supply  to  and  from  the  lower  limbs.  The  blood  is 
thin  and  poor  in  quality;  the  heart  is  weakened  and  unable  to 
force  the  blood  around  the  circuit  and  thus  overcome  the  resist- 
ance offered  by  the  pelvic  blood  vessels. 

The  treatment  for  such  conditions  consists  in  removing  ol)- 


REFLEX    DISORDERS.  481- 

structions  to  the  venous  return,  which  in  the  lower  limbs,  are 
found  in  the  saphenous  opening  or  at  the  iliac  veins.  Correcting 
partial  or  complete  dislocations  of  the  hip  and  innominate  bones, 
is  often  sufficient  to  overcome  this  condition  in  the  lower  limbs. 
Treat  to  increase  the  amount  of  pure  blood  and  the  rapidity  of 
the  blood  current,  this  being  accomplished  by  correcting  liver 
and  heart  diseases  as  well  as  local  disturbances  of  the  limbs. 

HYSTERIA  is  a  term  used  to  denote  certain  nervous  mani- 
festations not  due  to  organic  disease.  Formerly  it  was  thought 
to  be  due  to  uterine  disease,  hence  its  name,  but  is  now  regarded 
as  a  disorder  of  the  mind,  frequently  resulting  from  uterine  or 
ovarian  disease. 

It  is,  in  fact,  a  disease,  and  should  be  treated  as  such.  If 
there  is  a  disturbance  of  the  nervous  equilibrium  resulting  from 
an  imaginary  or  real  disease,  it  preys  on  the  patient's  mind  until 
she  gives  vent  to  her  feelings.  When  she  does  give  way  to  her 
feelings  and  loses  control  of  herself  we  call  it  hysteria. 

Hysteria  is  not  by  any  means  confined  to  the  female  sex,  but 
also  affects  the  male,  although  less  frequently.  Some  of  the  worst 
cases  of  hysteria  I  have  ever  seen,  were  in  the  male  in  which  there 
was  a  supposed  impotency. 

Hysteria  is  most  commonly  found  in  the  unmarried  and 
sterile;  the  shock  and  pain  of  childbirth  tending  to  prevent  its 
occurrence  in  multiparae.  Incases  of  malnutrition,  general  im- 
pairment of  the  ovary,  or  in  case  there  has  been  a  marked 
laceration  causing  a  loss  of  nerve  force,  hysteria  is  liable  to 
appear,  since  these  conditions  render  the  nervous  system  un- 
stable from  the  loss  of  nerve  force  or  the  lack  of  formation  of 
same. 

Ovarian  irritation  is  a  prolific  cause  of  hysteria.  That  part 
of  the  abdomen  over  the  ovary  is  especially  tender,  which  is  in- 

31 


482  DISEASES    OF    WOMEN. 

dicative  of  ovarian  congestion  or  inflammation,  and  in  some 
cases  the  ovary  is  prolapsed  and  congested  from  frequent  sexual 
excitements. 

Hysteria  commonly  occurs  in  people  who  do  not  have  to 
work  and  have  time  to  indulge  in  morbid  fancies.  Even  a  great 
DEAL  OF  MUSCULAR  WEAKNESS  or  fatigue  is  imaginary,  not  real. 
To  test  this  let  there  be  a  sudden  fright  and  the  patient  will  just 
^s  suddenly  forget  all  about  the  supposed  weakness. 

The  sensory  disturbances  in  hysteria  are  quite  well  marked. 
In  one  spot  or  region  there  will  be  hyperesthesia,  in  another  anes- 
thesia, the  hyperesthetic  regions  occurring  in  zones  or  belts  fol- 
lowing the  course  of  one  or  more  ribs.  The  patient  often  com- 
plains of  a  certain  tender  spot  which  varies  from  time  to  time  in 
position,  indicating  that  it  is  not  an  organic  disturbance. 

Others  apparently  have  a  fit  or  faint.  In  such  cases  ex- 
amine the  pulse  and  note  the  temperature.  If  the  pulse  is  reg- 
ular and  strong  and  the  patient  does  not  have  an  abnormal  tem- 
perature, that  is  neither  too  high  nor  too  low,  do  not  be  alarmed 
as  death  seldom  takes  place  under  such  conditions.  Also  ex- 
amine the  PUPILLARY  REFLEX.  This  is  done  by  touching  the 
■eyeball  with  the  finger.  If  it  is  hysteria,  the  patient  will  flinch 
and  suddenly  close  the  eye;  if  true  epilepsy  no  reflex  will  be  pres- 
ent, indicating  complete  unconsciousness.  Some  complain  of 
an  acute  pain  over  and  in  the  ovary.  If  it  is  real  the  patient  will 
not  forget  about  it  when  you  change  the  subject  of  conversation 
to  one  in  which  she  is  interested,  as  she  will  if  the  pain  is  imagi- 
nary. 

Numbness,  or  anesthesia,  is  sometimes  complained  of  but 
by  severely  pinching  the  parts  or  touching  them  with  the  lighted 
end  of  a  match  the  numbness  will  instantly  disappear.  If  the 
patient  is  truly  unconscious  she  will  not  resist  heat;  otherwise  she 


REFLEX    DISORDERS.  483 

will,  since  it  is  impossibe  to  so  control  the  muscles  that  a  reflex 
action  will  be  prevented  when  intense  heat  is  applied.  Of  course 
it  would  not  be  policy  to  resort  to  such  treatment  unless  the  diag- 
nosis were  certain. 

Globus  hystericus,  or  the  sensation  of  a  knot  in  the  throat 
which  interferes  with  deglutition,  is  a  common  symptom.  This 
is  due  to  a  contraction  of  the  throat,  swallowing  of  air  or  an  en- 
largement of  the  thyroid  gland.  Clavus  hystericus  is  a  symp- 
tom sometimes  found,  which  is  characterized  by  a  sharp,  local- 
ized pain  as  if  one  were  driving  a  nail  through  the  skull. 

Hysterical  contractures  and  paralyses  are  found,  the 
patient  firmly  believing  that  she  can  not  move  a  certain  joint, 
and  in  time  the  tendons  contract  producing  deformity  of  the 
parts.  Hysterical  aphonia  often  occurs  during  the  menstrual 
period.  I  remember  a  patient  treated  at  the  A.  T.  Still  Infirmary 
that  had  complete  aphonia  at  each  menstrual  period.  After 
some  neck  treatment,  but  especially  after  she  was  made  very 
ANGRY,  the  voice  returned.  In  many  such  cases  the  nervous 
system  has  to  be  changed,  this  being  best  accomplished  by  means 
of  a  shock. 

Quivering  of  the  eyelids  is  one  of  the  best  symptoms  of 
hysteria.  It  shows  a  forced  contraction  of  the  muscles,  which 
finally  tire  and  quiver.  In  some  there  is  a  hysterical  cough 
OR  CRY.  the  patient  being  completely  overcome  by  emotion.  Gas 
is  usually  found  in  the  stomach  and  intestines,  producing  tym- 
panites, borborygmus  and  eructations.  Hysterical  fevers 
or  temperatures  have  been  recorded,  in  which  the  thermometer 
registered  as  high  as  115  degrees  Fahrenheit.  The  hysterical 
CRY  or  groan  is  sometimes  found.  Cataleptic  or  trance-like 
conditions  or  spasms  with  opisthotonous  are  common  in  advanced 
cases  of  hysteria.  The  patient  tears  the  bedclothes,  retracts 
the  head  and  cannot  be  kept  in  any  one  position. 


484  DISEASES    OF   WOMEN. 

The  diagnosis  of  this  condition  is  sometimes  very  difficult 
as  well  as  important.  A  sad  mistake  would  be  made  if  a  real 
disease  were  treated  as  a  hysterical  one.  If  a  localized  lesion  is 
found,  it  matters  not  whether  there  is  a  hysterical  condition  or 
not,  if  the  lesion  is  corrected.  If  the  supposed  lesion  or  tender 
spot  varies  from  place  to  place  it  is  hysterical.  If  the  tempera- 
ture and  pulse  are  normal,  and  there  is  a  knot  or  swelling  in  the 
throat,  quivering  of  the  eyelids,  pupillary  reflex,  it  occurring  at  or 
near  the  periods,  ovarian  hyperesthesia  and  pain,  and  tender 
points  in  the  back,  changing  from  time  to  time  to  different  loca- 
tions, it  is  safe  to  pronounce  the  case  a  hysterical  one. 

The  treatment  is  one  directed  to  change  the  mind  into  differ- 
ent channels.  Pressure  over  the  transverse  process  of  the  atlas 
is  a  good  treatment  to  bring  the  patient  out  of  one  of  the  spasms. 
Pain  produced  in  any  part  of  the  body  is  often  sufficient  to  change 
the  thoughts  and  bring  the  patient  to  her  senses. 

The  patient  should  be  instructed  to  make  an  attempt  at 
SELF-CONTROL,  not  permitting  herself  to  give  way  to  her  feelings. 
Imaginary  operations  or  suggestive  treatments  are  quite  success- 
ful, if  the  patient  gets  the  idea  that  the  trouble  has  been  removed. 
In  such  cases  the  various  "healers"  are  successful  since  there  is  no 
organic  trouble.  Dr.  C.  E.  Still  had  a  patient  who  believed  that 
all  his  joints  were  dislocated  and  nothing  could  dislodge  that  idea 
until  each  joint  was  carefully  and  separately  treated  and  he  told 
it  had  been  replaced.  The  patient  immediately  recovered,  since 
it  was  only  an  imaginary  disease. 

Lesions  along  the  spine  and  lower  ribs  are  to  blame  for  some 
hysterical  cases,  by  producing  ovarian  or  uterine  disease  with 
the  accompanying  disturbances.  The  second  lumbar  is  the  most 
important  point,  and  in  the  majority  of  cases,  a  lesion  will  be 
found  at  that  point.     Uterine  displacement  should  be  corrected. 


REFLEX    DISORDERS.  485 

and  you  will  find  most  of  them  have,  to  hear  them  tell  it,  all  the 
diseases  peculiar  to  the  female  sex,  in  fact,  they  frequently  have 
"uterus  on  the  brain." 

HYSTERO-EPILEPSY  is  a  form  of  epilepsy  due  to  disease 
of  the  generative  organs,  usually  the  ovary.  It  is  character- 
ized by  an  attack  very  similar  to  epilepsy,  there  being  a  pro- 
dromal stage  in  which  there  are  the  aura,  the  stage  of  clonic 
contraction  and  the  stage  of  tonic  contraction,  followed  by  the 
stage  of  relaxation.  During  these  different  stages  the  patient 
is  in  most  cases  unconscious  and  sometimes  froths  at  the  mouth. 

If  a  chronic  case,  the  patient  has  that  dull,  stupid  expression 
characteristic  of  epilepsy,  which  is  indicative  of  impairment  of 
the  mind.  The  attacks  are  most  frequent  and  hardest  near  the 
menstrual  period  and  especially  just  following  the  cessation  of 
the  flow.  About  the  first  thing  noticed,  is  a  contraction  or,  as 
they  express  it,  a  ball,  lump  or  knot,  that  begins  to  form  in  the 
side  just  above  the  ovary,  the  left  being  more  frequently  affected. 
This  contraction  gradually  ascends  through  the  esophagus  to 
the  throat  and  when  it  reaches  that  point  the  patient  has  a  chok- 
ing sensation  and  becomes  unconscious.  This  is  the  diagnostic 
point  between  hystero-epilepsy  and  true  epilepsy.  Whenever 
the  aura  begin  in  the  ovary  and  ascend,  and  if  there  is  chronic 
uterine  or  ovarian  disease,  and  the  attack  is  associated  with  the 
menstrual  period,  it  is  in  most  cases  hystero-epilepsy. 

The  attacks  vary  in  number  from  one  to  a  dozen  per  day, 
being  followed  by  a  quiescent  period  of  several  days. 

The  lesions  in  such  cases  are  in  the  cervical  and  lumbar  re- 
gions. The  lesions  affecting  the  uterus  and  ovaries  are  the  pre- 
disposing causes;  the  cervical  lesions  the  exciting  causes,  which 
weaken  the  cerebral  circulation.  Displacement  of  the  lower 
ribs  may  excite  ovarian  disease  and  in  this  way  produce  epilepsy. 


486  DISEASES    OF    WOMEN. 

A  displaced  uterus  will  displace  the  ovaries/ thereby  setting  up  a 
disease  in  them.  If  this  '  ere  the  only  cause  every  displace- 
ment would  produce  epilepsy;  but  there  must  be  another  cause 
acting  in  conjunction  with  the  above  mentioned  ones  and  this 
is  found  to  be  a  lesion  in  the  neck,  which  weakens  the  blood 
supply  to  the  higher  centers. 

The  attacks  usually  occur  at  night.  There  is  hallucination, 
spasms  and  a  quiescent  stage,  during  which  the  patient  has  la- 
bored respiration  and  anesthesia.  The  recovery  is  gradual  and 
the  patient  does  not  remember  what  has  occurred.  The  urine 
is  limpid  and  increased  in  amount,  and  sometimes  involuntarily 
voided  during  an  attack.  In  rare  cases  the  tongue  is  bitten. 
The  muscles  are  sore  and  the  eyes  red  after  an  attack. 

The  treatment  consists  of  correction  of  the  ovarian  and 
uterine  disease,  and  the  bony  lesions  usually  found  in  the  lumbar, 
sacral  and  cervical  regions.  A  displaced  uterus  or  ovary  is  usually 
found,  upon  the  replacement  of  which  the  symptoms  frequently 
are  relieved.  After  the  attack  is  well  under  way  it  cannot  be 
stopped,  but  if  only  in  the  beginning,  strong  inhibition  in  the 
suboccipital  region  and  local  treatment  by  which  the  uterus  is 
lifted  up  will  often  ward  it  off. 

CATALEPSY  is  occasionally  found  accompanying  female 
diseases.  The  patient  becomes  perfectly  rigid,  unconscious  and 
remains  that  way  for  some  time.  A  sudden  uterine  displace- 
ment will  produce  this  condition.  Dr.  C.  E.  Still  reports  a  case 
in  which  a  woman  was  walking  along  the  street  and,  slipping  on 
the  walk,  fell  and  suddenly  became  unconscious  and  rigid.  The 
usual  restoratives  were  applied  but  to  no  avail.  He  was  then 
called  and  by  replacing  the  uterus,  instantly  relieved  the 
condition.  I  have  had  similar  cases  which  were  relieved  by  re- 
placing a  displaced  uterus  or  simply  changing  its  position.     If  the 


REFLEX    DISORDERS.  487 

condition  comes  on  suddenly  as  the  result  of  a  lift  or  fall  the 

UTERUS  IS  TO  BLAME  IN  NEARLY  EVERY  CASE.        After     the     USUal 

treatments  have  failed  to  relieve,  examine  the  pelvic  organs  for 
uterine  displacement,  since  this  is  the  cause  in  a  majority  of  all 
diseases  in  the  female,  and  particularly  if  a  history  of  a  fall  or 
strain  from  lifting  can  be  obtained. 


488  DISEASES    OF    WOMEN. 


MISCELLANEOUS  AFFECTIONS. 


STERILITY  is  not  a  disease  within  itself,  but  a  result  of  dis- 
eased or  badly  developed  sexual  organs.     By  sterility  is  meant 

the   LACK  OF  CAPACITY   FOR  IMPREGNATION   OR  CONCEPTION.       One 

marriage  out  of  every  seven  is  barren  and  the  per  cent,  is  on  the 
increase.  The  fault  is  usually  attributed  to  the  female,  but  the 
male  is  very  often  to  blame. 

In  order  to  understand  sterility  it  is  first  necessary  to  under- 
stand the  factors  that  enter  into  impregnation. 

The  cortical  portion  of  the  ovary  contains  Graafian  follicles 
in  which  are  the  ova.  At  the  maturity  of  a  follicle  it  ruptures, 
throwing  out  the  ovum  which  is  carried  by  way  of  the  Fallopian 
tubes  to  the  uterus.  If  at  this  time  semen  is  present  in  which  are 
the  active  spermatozoa,  union  takes  place,  supposedly  in  the  Fallo- 
pian tubes.  If  the  nidus  is  healthy  enough  to  nourish  the  now 
impregnated  ovum,  it  remains  firmly  attached  to  the  mucous 
lining.  Therefore,  in  order  that  impregnation  take  place  there 
must  be  a  union  of  the  ovum  and  the  spermatozoon  and  a  healthy 
nidus  from  which  nourishment  can  be  drawn.  From  this  it  can 
be  seen  that  sterility  would  follow  (1)  absence  of  one  or  both 
vital  elements;  (2)  prevention  of  union  of  the  two  vital  ele- 
ments; or  (3)  destruction  of  the  impregnated  ovum  just  after 
union  had  taken  place. 

Absence  of  the  spermatozoon  is  the  result  of  disease  or 
weakness  of  the  testes.  In  gonorrheal  subjects,  or  in  those  ad- 
dicted to  the  practice  of  masturbation,  or  excessive  venery  the 
semen  often  lacks  the  vital  element.  To  test  the  semen,  a 
microscopic   examination   should   be    made   whereby   the   sper- 


MISCELLANEOUS    AFFECTIONS.  489 

matozoa  can  be  seen  if  present.  They  are  active  and  resemble 
tadpoles  in  shape. 

Ovarian  disease,  such  as  ovaritis,  tumors,  atrophy  or  non- 
development,  prevents  the  maturing  of  the  Graafian  follicles 
and  escape  of  the  ova,  thus  producing  sterility.  In  the  obese 
the  ovary  is  usually  inactive,  hence  the  amenorrhea  and  sterility. 

Lesions  affecting  the  ovarian  centers  impair  the  activity  of 
the  ovary  and  cause  sterility.  This  has  been  proven  by  cases 
treated  by  us.  These  lesions  also  interfere  with  the  proper  devel- 
opment of  the  ovaries  and  uterus.  A  poorly  or  non-developed 
uterus  is  very  often  the  cause  of  sterility.  There  is  usually  an 
anteflexion,  the  cervix  being  drawn  forward  and  distorted,  and 
the  anterior  lip  flattened  in  many  cases.  After  several  years 
of  MARRIED  LIFE  the  ovaries  and  uterus  sometimes  become  de- 
veloped and  impregnation  takes  place.  If  impregnation  does 
not  occur  within  four  or  five  ^-ears  after  marriage,  the  chances 
are  that  the  case  is  incurable,  although  the  writer  has  cured 
eases  of  many  years  standing,  by  correcting  spinal  and  visceral 
lesions.  A  small  uterus  with  a  conical  or  flattened  cervix  and  a 
pin-hole  os  is  almost  pathognomonic  of  sterility. 

The  ovum  may  be  prevented  from  reaching  the  tubes  or 
uterus  by  disease  of  the  tubes,  such  as  salpingitis  or  a  closure  of 
the  canal.  The  spermatozoon  may  be  prevented  from  reaching 
the  tubes  by  an  acute  flexion,  stenosis,  atresia  of  the  vagina  or  a 
closure  of  the  uterine  end  of  the  tubes.  Abnormalities  which 
prevent  intercourse  in  a  similar  way  cause  sterility. 

Diseases  of  the  vagina  which  prevent  intercourse,  such  as 
vaginismus,  vaginitis  or  an  inflammatory  condition  of  the  urethra 
and  vulva,  also  cause  sterility.  Again,  the  spermatozoa 
MAY  BE  destroyed  after  they  have  been  deposited  in  the  vagina. 
If  the  environment  is  suitable  they  will  live  for  some  time.  Acid 
secretions  destrov  them,  since  thev  are  alkaline. 


490  DISEASES    OF    WOMEN. 

Leucorrheal  discharges,  by  counteracting  the  spermatozoa, 
cause  sterility.  Metritis  and  endometritis  also  predispose  to 
sterility.  A  lacerated  cervix  causes  both  metritis  and  endo- 
metritis with  the  attending  leucorrheal  discharge.  Endometri- 
tis causes  sterility,  not  only  by  destroying  the  spermatozoa  but 
by  weakening  or  destroying  the  nidus  which  should  be  ready  for 
the  reception  of  the  impregnated  ovum.  Constitutional  dis- 
eases such  as  anemia  and  scrofula,  in  which  the  blood  is  thin, 
tend  to  produce  sterility.  The  ovaries  are  inactive,  the  Graafian 
follicles  do  not  develop  and  rupture,  hence  the  ovum  is  not  ma- 
tured. 

THE  TREATMENT  should  as  in  every  disease,  be  applied  to 
the  existing  cause.  Be  sure  the  trouble  is  not  in  the  husband, 
for  in  this  age  in  which  gonorrhea  and  masturbation  are  so  com- 
mon, the  male  is  very  often  to  blame.  If  the  ovaries  are  inactive, 
endeavor  to  correct  the  lesions  which  impair  their  influence, 
these  being  found  in  the  lower  dorsal  region  or  in  the  lower  ribs. 
If  there  is  a  flexion  or  a  stenosis  of  the  os  uteri,  it  should  be  cor- 
rected; if  leucorrhea  exists  to  any  great  extent  it  should  be  re- 
lieved since  the  acidity  will  counteract  the  alkalinity  of  the  sper- 
matozoa. Inflammatory  conditions  must  be  overcome  before 
the  condition  can  be  cured.  The  best  treatment,  and  the  one 
with  which  I  am  most  successful,  is  one  applied  to  the  lower  dor- 
sal and  upper  lumbar  regions.  Strong  stimulation  and  manip- 
ulation of  the  spinal  column  by  which  each  vertebra  is  adjusted, 
FREE  the  blood  AND  NERVE  SUPPLY  to  the  pelvic  organs,  which 
is  necessary  to  their  health.  If  the  general  health  is  impaired 
it  will  have  to  be  built  up,  otherwise  impregnation  will  not  take 
place,  or,  if  it  does,  abortion  is  likely  to  follow. 

LEUCORRHEA  is  another  condition  which  is  a  symptom  of 
SOME  VASCULAR  DISTURBANCE    affecting  the    mucous    secreting 


MISCELLANEOUS   AFFECTIONS.  491 

glands  of  the  vagina  and  uterus.  It  is  defined  as  a  muco-puru- 
lent  discharge,  popularly  called  the  "whites,"  from  the  female 
genital  tract.  The  discharge  comes  either  from  the  vaginal  walls 
or  the  uterus,  hence  the  division  into  vaginal  and  uterine  leucor- 
rhea. 

Normally  there  is  a  secretion  from  the  vagina  just  suffi- 
cient TO  lubricate  THE  PARTS.  This  is  a  clear,  transparent, 
glairy  fluid  like  the  white  of  an  egg.  That  from  the  uterus  is 
alkaline;  that  from  the  vagina  acid.  When  these  secretions  are 
abnormal  in  quality,  or  especially  m  quantity,  it  is  called  leucor- 
rhea.  As  mentioned  before,  an  increased  arterial  blood  flow  to 
a  gland  increases  its  physiolgical  secretion ,  while  an  increased 
venous  flow  produces  a  pathological  secretion. 

CAUSES.  The  cause  of  leucorrhea  depends  upon  a  venous 
congestion  of  the  uterus  and  vaginal  walls,  usually  the  result  of 
obstruction  or  vaso-motor  paralysis.  The  use  of  w^\rm  water 
DOUCHES  is  a  common  cause.  Nearly  all  women  use  them  and 
about  ninety  per  cent,  have  leucorrhea.  They  are  especially 
important  as  causes,  if  used  daily.  Warm  water  dilates  the 
blood  vessels,  producing  a  slowing  of  the  blood  current.  From 
this  will  result  a  lowering  of  the  vitality  of  the  blood  with  its 
increased  amount  of  poisonous  materials,  which  go  to  make  up 
the  venous  condition.  This  affects  the  activity  of  the  glands 
and  produces  a  weakness  in  the  uterus  and  supports,  following 
which  DISPLACEMENTS  and  MENSTRUAL  DISORDERS  are  found. 
In  the  parous  woman  examine  for  a  lacerated  cervix.  If  the  in- 
jury is  very  long  in  healing,  the  parts  become  congested  and  fol- 
lowing this  is  usually  an  abnormal  secretion. 

Sometimes  an  erosion  or  ulceration  is  present.  In  such 
cases  there  is  a  constant  irritation,  ache,  and  discharge  of  a  muco- 
purulent nature. 


492  DISEASES    OF    WOMEN. 

A  displaced  uterus  causes  a  congestion  of  the  different  glands, 
hence  is  a  common  cause  of  leucorrhea.  The  discliarge  is  worse 
during  the  menstrual  period,  since  the  parts  are  more  congested 
at  that  time. 

Vaginitis,  either  simple  or  specific,  is  a  cause  of  the  va- 
ginal form.  Gonorrheal  vaginitis,  especially  in  the  latent  or 
chronic  form,  is  quite  a  prominent  cause. 

Bony  lesions  which  interfere  with  the  vaso-motor  supply, 
are  the  most  important  causes  as  viewed  from  the  osteopathic 
standpoint.  These  lesions  are  found  in  the  lower  part  of  the 
spine  in  the  form  of  a  subluxated  vertebra  or  a  curvature,  and  in 
the  pelvic  region  in  the  form  of  a  displaced  innominate,  sacrum 
or  coccyx.  Case  after  case  can  be  cited  in  which  cures  were 
effected  by  simply  correcting  the  bony  lesions. 

In  some  cases  leucorrhea  is  due  to  general  debility  the 
result  of  stomach  affections  or  constitutional  diseases.  I  have 
seen  cases  follow  attacks  of  typhoid  fever.  In  such  cases  a  le- 
sion is  found  in  the  middle  or  lower  dorsal  region  affecting  the 
nutrition,  and  from  poor  nutrition  results  disturbed  se- 
cretions. The  uterus  and  vagina  share  in  the  general  weak- 
ness and  leucorrhea  is  the  consequence.  Remember  that  a 
venous  congestion  is  a  condition  always  found  in  leucorrhea, 
whether  due  to  inhibition  of  the  vaso-motor  nerves  or  a  mechan- 
ical obstruction  preventing  free  return  of  the  blood  to  the  heart. 

SYMPTOMS.  The  principal  symptoms  of  leucorrhea,  besides 
the  discharge,  are  backache,  general  weakness  and  menstrual 
disorders,  especially  too  long  and  profuse  menstruation.  The 
discharge  has  in  most  cases  a  very  disagreeable  odor  on  account 
of  the  decomposition  which  has  taken  place.  If  chronic,  it  des- 
iccates and  forms  into  lumps,  while  in  the  early  stages  it  is  of  a 
slimy,  glairy  nature.     This  discharge,  from  the  color  and  its  ef- 


MISCELLANEOUS    AFFECTIONS.  493 

feet  on  the  nervous  system,  has  given  rise  to  the  belief  among  the 
laity  that  the  white  stuff  is  the  spinal  marrow  which  melts  and 
escapes  through  the  genital  tract. 

During  an  attack  of  epilepsy  this  discharge  is  markedly  in- 
creased. Uterine  displacements,  standing  on  the  feet,  and  vari- 
ous diseases  increase  the  amount  of  the  discharge.  All  abnormal 
discharges,  whether  the  color  is  white  or  tinged  with  blood,  are 
classified  under  the  head  of  leucorrhea. 

PROGNOSIS.  The  prognosis  is  very  uncertain.  Some  cases 
yield  very  readily  to  treatment,  while  others  are  slow.  If  the 
cause  is  readily  found  and  can  be  easily  corrected  it  is  favorable, 
but  if  it  occurs  in  an  anemic,  weak  person  in  whom  the  blood  is 
thin,  the  progosis  is  unfavorable  for  a  rapid  cure. 

TREATMENT.  The  treatment  consists  in  relieving  the  con- 
gestion of  the  uterus,  which  is  accomplished  by  locating  the 
cause  and  correcting  it  in  each  individual  case.  It  is  one  of  the 
most  common  disorders,  and  one  which  is  due  to  many  causes, 
hence  the  treatment  mvist  be  given  according  to  the  causes  in 
the  individual  case. 

In  the  first  place,  correct  the  bony  lesions,  whether  in 
the  dorsal,  lumbar  or  sacral  region;  also  uterine  displacements, 
since  they  cause  venous  stasis.  Treat  over  the  veins  leading 
from  the  uterus,  in  this  way  relieving  the  stagnated  condition  in 
the  uterus.  Strong  stimulation  of  the  nerves  in  the  lower  lum- 
bar and  sacral  regions  is  very  good  and  tends  to  restore  tonicity 
to  the  vessel  walls.  By  correcting  the  anatomical  derangements, 
assimilation  is  improved,  glandular  action  regulated  and  secre- 
tions made  normal.  If  the  leucorrhea  is  due  to  a  general  or 
constitutional  disease,  the  general  health  must  be  improved  be- 
fore a  cure  is  effected.  Douches  are  sometimes  necessary  for 
the  sake  of  cleanliness  and  should  be  used  occasionallv  if  the  odor 


494 


DISEASES    OF    WOMEN. 


becomes  too  offensive.  Salt  added  to  the  water  is  of  value  in 
cleansing  the  parts.  Some  claim  that  leucorrhea  can  be  cured 
by  the  repeated  use  of  saline  injections.  Perhaps  the  secretion 
can  be  lessened  in  amount,  or  even  temporarily  checked,  but  the 
cause  remains  and  the  effect  will  return. 

I  once  heard  the  "Old  Doctor"  say  that  the  exudate  thrown 
out  in  tonsillitis  or  in  any  sore,  that  is  the  scab,  is  for  the  purpose 


Fai 
Lobttle  unravelled 

Lobtdef 


Lactiferous  duet. 
Ampulla. 
Loculi  in  connective  tissue. 


Fig.  108. — Dissection  of  the  lower  half  of  the  female  breast  during  the 
period  of  lactation.  — (Luscka.) 

OF    PROTECTING    THE    INFLAMED    Or    DISEASED    SURFACE    wMch    it 

covers.  Perhaps  leucorrhea  acts  in  a  similar  way;  that  is,  the 
uterus  and  vagina  throw  out  a  secretion  which  coats  the  inflam- 
ed mucous  membrane,  thus  protecting  it.  If  this  is  true,  it  sug- 
gests   that  primarily,  leucorrhea  is  due  to    an  inflamed   surface 


MISCELLANEOUS   AFFECTIOXS.  495 

which  nature  is  trying  to  protect  and  that  astringents  used  to 
destroy  or  remove  this  secretion  are  injurious  rather  than  help- 
ful. We  know  this  is  true  of  the  various  throat  washes  or 
gargles,  such  being  harmful  in  tonsillitis  and  pharyngitis.  In 
the  very  chronic  cases  in  which  the  secretions  have  been  de- 
posited in  quantities  in  the  fornices.  they  should  be  removed. 
This  can  be  done  with  dressing  forceps  and  absorbent  cotton. 

MASTURBATION  is  a  vice  which  has  become  very  prevalent. 
Although  not  practiced  so  extensively  by  the  female  as  by  the 
male,  its  effects  can  be  seen  depicted  on  the  faces  of  many.  In 
some  it  is  the  result  of  disease;  in  others  it  has  been  brought  on 
by  obscene  literature  or  bad  associations.  A  lesion  which  stim- 
ulates the  PUDic  nerve  will  often  lead  to  masturbation.  This 
lesion  is  usually  found  in  the  lower  dorsal  region.  An  adhered 
clitoris,  uncleanliness  or  pruritus  vulvae  are  common  causes.  It 
is  most  commonly  found  in  the  young,  but  occasionally  in  the 
adult. 

"A  very  serious  mistake  in  general  is  made  as  to  the  loca- 
tion of  the  parts  which  play  the  chief  part  in  the  orgasm.  The 
clitoris  in  the  female  is  usually  put  down  as  the  part  chiefly  in- 
volved. Whether  in  the  male  or  the  female,  the  urethra  is  the 
part  in  which  the  orgasm  occurs.  In  the  male  it  is  caused  by  the 
passing  of  jets  of  semen  over  the  mucous  membrane  of  the  urethral 
canal.  In  the  female,  by  jets  of  mucus  from  the  neck  of  the 
bladder  through  the  urethra.  After  an  orgasm  in  the  female, 
Tiowever  produced,  the  labia  and  vestibule  are  flooded  with  mu- 
cus, which  escapes  not  from  the  vagina  altogether,  but  largely 
from  the  urethra.  The  reason  why  males  who  have  suffered 
amputation  of  the  glans,  and  women  who  have  been  deprived  of 
the  glans  of  the  clitoris  can  still  accomplish  the  sexual  act  with 
orgasm,  is  because  the  urethra  is  the  seat  of  the  peculiar  nerve 


496  DISEASES    OF    WOMEN. 

distribution  necessary  for  its  production.  This  explains  the 
habit  of  some  individuals  of  passing  all  manner  of  objects  into 
the  urethra,  and  even  masturbating  that  way." 

SYMPTOMS.  Masturbation,  at  first,  if  not  excessive,  pres- 
sents  no  special  symptoms.  If  excessive,  it  first  shows  itself  in 
the  form  of  nervousness.  The  complexion  is  pale,  sallow,  and 
the  eyes  sunken  and  surrounded  by  dark  rings;  the  patient  is 
bashful  and  has  a  secretive,  downcast  expression;  the  hands  and 
feet  are  cold,  the  skin  clammy,  circulation  poor,  there  being  a 
small,  rapid,  weak  pulse  and  shortness  of  breath.  The  general 
health  becomes  deteriorated  and  the  patient  non-energetic.  The 
step  is  not  elastic  and  the  victim  is  given  to  morbid  fancies. 
In  chilrden  convulsions  or  spasms  may  develop,  which  are 
very  hard  to  understand.  I  have  seen  cases  of  spasms  which 
would  occur  only  at  night,  cured  by  correcting  a  diseased  clitoris 
which  had  brought  on  masturbation.  In  describing  the  signs 
Dickinson,  in  American  Gynecology,  says:  "The  type  of  full 
development  of  the  deformity  consists  in  a  finely  wrinkled  and 
deeply  pigmented  enlargement  of  the  labia  majora  and  hyper- 
trophy of  some  adjacent  structures.  Thickened,  enlongated, 
curled  on  themselves,  thrown  into  tiny,  close-set,  irregular  folds 
that  cross  at  all  angles,  as  in  a  cock's  comb,  the  lesser  labia  pro- 
trude in  all  positions  through  the  larger  labia.  The  pigment 
deposit  varies  with  the  general  type  of  coloring.  One  labium  is 
sometimes  greater  than  its  fellow.  The  follicles  are  often  con- 
spicuous as  whitish  spots,  the  prepuce  commonly,  and  the 
fourchette  occasionally,  participate  in  the  corrugation  and  dusk- 
iness, or  one  of  these  may  alone  be  affected.  At  times  a  wrinkled 
band  runs  off  to  the  labium  majus.  Certain  veins  near  the  clit- 
oris stand  out.  At  the  mouths  of  each  urethral  gland  a  flap-like 
protrusion  may  be  seen.     Greater  size  and  power  of  the  pelvic 


MISCELLANEOUS    AFFECTIONS.  497 

floor  accompany  the  other  hypertrophies.  Distinctive  increase 
in  the  size  of  the  cUtoris  may  be  present,  but  contrary  to  the  gen- 
eral belief,  it  is  infrequent.  There  may  be  enlargement  and 
changes  in  the  areolae  or  in  the  breasts,  resembling  those  of  preg- 
nancy. At  a  later  stage  flabbiness  of  the  labia  majora,  or  pig- 
ment spots  denote  atrophy  of  the  structures  once  enlarged,  but 
the  small  marks  never  disappear.  Some  part  or  the  whole  of 
these  alterations  occur  in  about  one  third  of  those  women  who 
suffer  from  pelvic  disorders.  One  fourth  of  the  patients  present- 
ing hypertrophies  belong  to  the  neurotic  class.  These  altera- 
tion are  due  to  oft-repeated,  prolonged  sexual  excitation,  irre- 
spective of  coitus  or  gestation.  Pressure  or  friction  causes  them. 
Pregnancy  produces  increase  of  size  and  some  surface  irregu- 
larity, but  never  the  fully  developed  changes  here  specified." 

The  most  important  effect  of  masturbation  is  on  the  nerv- 
ous system.  Nervousness,  morbid  fears  and  fancies,  melan- 
cholia, solitude  and  loss  of  memory  are  common.  In  nearly  all 
cases  there  is  ovarian  pain,  the  result  of  repeated  congestion  of 
the  ovary.  Another  effect  is  that  of  bowel  disease.  One  writer 
says:  "Next  in  importance  is  the  disturbance  of  the  intestinal 
functions.  Intestinal  indigestion,  distention  with  gas;  wake- 
fulness, as  a  consequence,  is  common  in  these  patients.  A  pe- 
culiarly obstinate  constipation  is  a  most  common  accompaniment. 
During  the  manipulation  of  the  genitals,  the  sphincter  and  leva- 
tor ani  muscles  are  contracted  to  the  utmost.  It  is  a  part  of 
the  process  whereby  an  orgasm  is  produced.  The  result  is  a 
tonic  contraction  of  the  sphincter  ani  muscle.  Constant 
taking  of  laxatives  or  cathartics  adds  to  the  trouble  by  destroy- 
ing the  muscular  tone  of  the  rectum  and  colon.  An  examina- 
tion of  the  rectum  in  these  cases  shows  the  mucous  membrane 
relaxed  and  frequently  in  deep  and  multitudinous  folds,  filled 

32 


498  DISEASES   OF    WOMEN. 

with  glairy  mucus;  the  sphincter  will  scarcely  admit  the  well- 
oiled  finger." 

TREATMENT.  The  treatment  consists  of  two  things;  first, 
bringing  to  bear  a  moral  suasion  if  the  patient  is  accountable; 
second,  removing  the  source  of  irritation  which  provokes  the 
practice.  In  those  who  are  naturally  passionate  a  vegetable 
diet,  as  well  as  morality,  should  be  enforced. 

Work,  either  physical  or  mental,  by  which  the  mind  is  busied, 
is  one  of  the  best  remedies-  If  the  patient  is  idle,  with  nothing 
to  occupy  the  mind,  masturbation  is  very  apt  to  be  contracted; 
but  if  the  mind  is  busy  there  is  no  room  for  evil  thoughts.     The 

BLOOD  IS  DISTRIBUTED  TO  EVERY  ORGAN  ACCORDING  TO  THE  ACTIV- 
ITY OF  THAT  ORGAN.  If  the  patient  constantly  has  sexual  irri- 
tation from  the  influence  of  the  higher  centers,  the  organs  become 
congested  and  secretions  increased.  Cold  baths  are  beneficial 
in  that  they  stimulate  the  circulation  and  cause  equal  distribu- 
tion of  the  blood.  Again,  if  there  are  lesions  they  should  be  re- 
moved. I  have  seen  cases  of  nymphomania  cured  by  correcting 
a  lesion  at  the  tenth  dorsal  vertebra,  which  in  some  way 
caused  a  stimulation  of  the  pudic  nerve. 

The  removal  of  smegma  or  local  accumulations  of  filth  about 
the  clitoris  is  necessary,  since  any  local  irritation  has  a  tendency 
to  lead  to  the  condition.  Sleeping  on  the  back  is  contra-in- 
dicated, since  the  centers  in  the  cord  controlling  the  sexual  organs 
become  congested  and  deranged  by  the  settling  of  blood,  that  is, 
the  hypostatic  congestion  while  in  that  position. 

ABORTION  is  technically  defined  as  the  expulsion  of  the  pro- 
ducts of  conception  at,  or  before,  the  third  month,  but  ordinarily 
it  is  understood  to  be  the  termination  of  pregnancy  before  the 
seventh  month  or  viability.  Abortion  occurs  quite  often;  at 
least  twenty-five  per  cent,  of  ail  c&ses  of  pregnancy  abort,  and 


MISCELLANEOUS   AFFECTIONS.  499 

the  practitioner  will  be  called  upon  to  treat  such  cases,  or  at  least 
to  diagnose  them.  In  some,  abortion  becomes  habitual.  The 
WRECK  of  many  a  woman's  constitution  can  be  traced  to  one 
or  repeated  abortions.  It  may  occur  at  the  first  month,  the  pa- 
tient thinking  it  a  case  of  membranous  dysmenorrhea  accompanied 
by  flooding,  or  it  may  occur  at  the  third  month,  at  which  time  it 
is  most  common,  probably  on  account  of  the  formation  of  the 
placenta  at  this  time. 

CAUSES.  Abortion  depends  especially  upon  one  thing, 
viz:  STRONG  UTERINE  CONTRACTION;  Consequently,  anything 
that  will  bring  on  marked  uterine  contractions  will  bring  on 
abortion.  A  weakened  attachment  of  the  embryo  is  a  predis- 
posing cause.  It  may  be  caused  by  disease  of  the  fetal  append- 
ages, malposition  of  the  placenta  and  abnormalities  of  the  cord. 
Paternal  causes  are  sometimes  found,  such  as  syphilis,  or  where 
the  spermatozoa  are  weakened  from  constitutional  diseases,  ven- 
ereal diseases,  excesses,  masturbation  or  extreme  old  age.  Ma- 
ternal causes  are  common,  such  as  the  exanthemata  or  other 
diseases,  systemic  poisons,  or  lesions  along  the  lower  part  of 
the  spine.  These  lesions  weaken  the  uterus,  hence  the  attach- 
ment of  the  ovum  is  insecure.  All  forms  of  traumatism,  such 
as  blows,  strains  or  the  lifting  of  heavy  weights,  produce  abortion 
if  there  are  any  predisposing  causes.  The  introduction  of  in- 
struments INTO  THE  UTERINE  CAVITY,  such  as  a  sound  or  cathe- 
ter, persistent  vomiting,  hiccoughing  or  sneezing  may  produce 
it.  It  may  be  brought  on  by  various  reflex  causes,  such  as  vio- 
lent emotion  or  sudden  excitement,  if  severe  enough,  or  if  there 
is  a  marked  predisposition. 

Produced  abortion  is  the  result  of  the  introduction  of  instru- 
ments into  the  uterus  or  by  the  ingestion  of  certain  drugs,  such 
as  tansy,  ergot  or  pennyroyal. 


500  DISEASES    OF    WOMEN. 

To  the  osteopath  the  lesions  are  the  most  important, 
and  if  such  exist  in  a  pregnant  woman,  be  very  careful  not  to 
produce  pain  while  treating  the  patient,  since  abortion  may 
occur.     Again,  by  properly  treating  such  lesions,  abortion 

M.\Y  BE  prevented. 

SYMPTOMS.  The  symptoms  vary  with  the  stage  to  which 
gestation  has  advanced.  The  prodromal  symptoms  are:  sense 
of  discomfort  in  the  pelvis,  pain  in  the  lumbar  and  sacral  regions 
and  a  general  uneasy  feeling.  These  symptoms  are  followed  by 
hemorrhage,  viterine  contractions  or  labor  pains  and  finally  by 
the  expulsion  of  the  embryo  or  a  part  of  the  products  of  concep- 
tion. 

The  cervix,  on  local  examination,  will  be  found  soft  and 
the  OS  patulous,  if  it  is  a  case  of  inevitable  abortion  or  if  it 
has  already  taken  place.  The  mammary  glands  will  be  found 
enlarged  and  the  milk  secretion  will  usually  occur  at  the  third 
day  after  abortion. 

The  diagnosis  is  made  by  finding  the  embryo  or  its  mem- 
branes. Often  these  are  lost,  the  mother  not  thinking  of  their 
diagnostic  value,  thus  making  it  hard  to  diagnose.  If  there  is 
retention  of  the  membranes  it  may  give  rise  to  puerperal  fever, 
or  if  chronic,  the  symptoms  may  be  similar  to  those  of  a  dead 
fetus,  cancer  or  sloughing  polypus. 

The  AFTER  EFFECTS  or  scquclac  are  of  most  interest  to  the 
gynecologist.  The  local  after  effects  are  those  resulting  from 
subinvolution.  The  uterus  remains  large,  soft  and  vascular  for 
several  months ;  a  relaxation  of  the  uterine  supports  permits  dis- 
placements to  occur  from  any  exciting  cause;  the  vaginal  walls  are 
smooth,  that  is  the  rugae  are  absent,  but  folds  of  mucous  mem- 
brane are  present  in  their  stead;  the  os  is  patulous,  the  cervix 
short  and  thick.     Leucorrhe.\  in  a  verv  bad  form  usuallv  com- 


MISCELLANEOUS    AFFECTIONS.  501 

plicates.  The  nervous  sj-mptoms  are  the  most  important,  tha 
patient  sometimes  becoming  a  nervous  wreck.  Neurasthenia, 
nervous  prostration  and  general  malnutrition  are  common  se- 
quelae. 

TREATMENT.  The  prophylactic  treatment  consists  in  cor- 
recting lesions  which  weaken  the  uterus,  and  preventing  any 
EXCITING  cause  which  would  bring  on  uterine  contractions. 
Avoid  strains,  traumatism  and  emotional  excitements,  since 
they  produce  abortion  if  any  predispositon  exists. 

The  TREATMENT  of  threatened  abortion  consists  in  putting 
the  patient  to  bed  and  keeping  her  perfectly  quiet  with  the  hips 
elevated.  Stimulation  of  the  clitoris  causes  contraction  of  the 
cervix;  this  is  accomplished  by  pressing  on  the  clitoris  wdth  the 
thumb  and  then  letting  it  suddenly  slip  off.  This  is  productive 
of  pain  which  causes  retraction  of  the  uterus.  If  the  cervix  is 
not  obliterated  and  os  has  not  dilated  to  any  degree,  the  abortion 
can  be  stopped  in  this  way. 

Inevitable  abortion  follows  dilatation  of  the  os  uteri.  In 
such  cases  the  treatment  is  almost  identical  with  that  given  in 
normal  labor,  that  is,  inhibition  of  the  clitoris  to  relax  the  cervi- 
cal muscle  fibers,  and  stimulation  of  lumbar  region  to  bring  on 
contraction  of  the  fundus  or  labor  pains.  If  the  membranes  are 
not  expelled  on  account  of  non-loosening  of  the  placenta  and 
NO  HEMORRHAGE  IS  PRESENT,  wait  awhilc  for  the  uterine  contrac- 
tions to  loosen  it.  After  the  placenta  has  been  separated  from 
the  uterus,  remove  by  means  of  a  pair  of  abortion  forceps.  Pro- 
duce contraction  of  the  uterus  to  prevent  hemorrhage,  keep  the 
patient  quiet  until  involution  is  well  under  way,  and  the  re- 
covery is,  as  a  rule,  rapid. 

The  diagnosis  is  the  principal  point  of  interest  to  the  gyne- 
cologist, and  to  be  sure  of  this,  consider  the  early  signs  of  preg- 


502  DISEASES    OF    WOMEN. 

nancy,  hemorrhage,  size  of  os,  onset,  reflex  disturbances  and 
history  of  case.  All  hemorrhages  in  married  women  are  to 
be  regarded  with  suspicion. 

The  immediate  dangers  are  hemorrhage,  laceration  and 
puerperal  fever  from  retention  of  a  part  of  the  fetal  membranes. 
The  secondary  dangers  are  habitual  abortion,  uterine  displace- 
ments and  subinvolution,  which  cause  chronic  backache,  head- 
ache, menstrual  disorders,  inflammation  of  the  uterus,  and  a 
general  sense  of  weakness  or  fatigue. 

ECTOPIC  GESTATION  and  extra-uterine  pregnancy  are 
terms  used  to  denote  that  gestation  has  occurred  outside  of  the 
uterine  cavity.  It  is  a  rare  condition,  but  is  occasionally  found. 
It  may  take  place  in  the  tubes,  peritoneal  cavity  or  the  ovaries. 
It  is  supposed  to  be  due  to  retention  of  the  ovum  in  those  places 
from  some  interference  with  its  transmission  to  the  uterus,  and 
the  union  with  the  spermatozoon  therefore  taking  place  at  that 
point.  Chronic  salpingitis,  displacements  of  the  ovary  or  chron- 
ic peritonitis  tend  to  destroy  the  ciliated  epithelium,  therefore 
preventing  the  transportation  of  the  ovum  to  the  uterus.  Since 
the  ovum  is  not  self-mobile  and  depends  upon  the  external  in- 
fluences for  its  movements,  and  the  spermatozoon  has  the  power 
of  locomotion,  therefore  if  the  ciliated  epithelium  were  destroyed 
the  ovum  would  be  retained  in  the  peritoneal  cavity  while  the 
spermatozoon  would  travel  upward  through  the  tube  unless  the 
lumen  were  completely  occluded. 

The  symptoms  of  extra-uterine  pregnancy  are  very  similar 
to  those  of  normal  gestation.  The  reflex  symptoms  are  the 
same;  the  gastric  disturbances  are  even  more  marked.  Menstrua- 
tion usually  ceases,  but  in  some  cases  it  is  not  disturbed;  in  others 
it  is  irregular.  There  is  a  discharge  of  blood  mingled  with  shreds 
of  broken  down  deciduae.     This  sj^mptom  indicating  the  for- 


MISCELLANEOUS    AFFECTIONS.  503 

mation  of  the  decidua  vera  is  one  of  the  most  important.  The 
uterus  is  somewhat  enlarged  but  not  so  much  as  in  normal 
pregnancy.  The  tumor  is  found  at  the  side  of  the  median  line. 
It  is  PAINFUL  and  grows  rapidly,  and  on  bimanual  examination 
is  found  to  be  fluctuating,  soft  and  very  sensitive.  Pelvic  pains 
are  usually  very   sharp  and  tearing  in  character. 

A  positive  diagnosis  is  impossible  before  rupture  of  the  sac, 
which  occurs  at  about  the  fourth  month.  However,  if  the  early 
SIGNS  of  pregnancy  ARE  PRESENT,  early  appearance  of  sharp, 
cramping,  pelvic  pains,  irregular  hemorrhages,  the  uterus  not 
very  much  enlarged,  os  dilated  and  cervix  soft,  and  shreds  of 
deciduae  discharged,  it  is  probably  a  case  of  extra-uterine  preg- 
nancy. If,  in  addition,  a  sensitive,  soft,  rapid-growing  tumor  is 
located  in  the  region  of  one  of  the  Fallopian  tubes,  it  indicates 
ectopic  gestation.  The  treatment, which  is  surgical,  consists  of  the 
removal  of  the  mass  b}^  abdominal  section.  If  rupture  of  the  sac 
does  not  occur,  as  it  usually  does  at  the  fourth  month,  it  may 
be  retained  for  years,  being  partly  absorbed  and  mummified. 

At  term  the  mother  has  what  is  called  spurious  labor,  since 
she  has  all  the  symptoms  of  labor  without  expulsion  of  the  fetus. 
If  rupture  takes  place  death  usually  follows,  unless  prevented  by 
surgical  intervention. 

THE  MAMMARY  GLANDS  are  the  seat  of  a  great  many  dis- 
orders, many  of  which  are  reflex  from  the  pelvic  organs.  Since 
they  are  a  part  of  the  sexual  system,  the  gynecologist  will  be  call- 
ed upon  to  treat  disorders  occurring  in  them. 

They  are  two  glands  which  extend  from  the  third  to  the 
seventh  rib,  from  the  sternal  border  to  the  mid-axillary  line. 
Their  size  and  prominence  depend  upon  a  great  many  things,  but 
principally  upon  sexual  activity  and  whether  the  patient  is  a 
nullipara  or  multipara.     The  nipple  is  located  on  a  level  with  the 


504  DISEASES  OF    WOMEN. 

fourth  rib  and  is  directed  outward  and  upward.  The  integument 
covering  the  nipple  is  pigmented,  the  amount  varying  with  the 
complexion  of  the  patient  and  whether  pregnancy  has  existed. 
The  gland  proper  is  composed  of  separate  glands,  about  twenty 
in  number,  which  open  by  half  as  many  ducts  at  the  nipple.  The 
nipple  has  unstriped  muscle  fibers,  on  account  of  which  erection 
may  take  place. 

The  BLOOD  VESSELS  come  principally  from  the  mammary 
artery  byway  of  its  perforating  branches  through  the  second,  third 
and  fourth  intercostal  spaces.  Some  branches  from  the  axillary 
artery  also  supply  the  gland.  The  veins  accompany  the  arteries. 
The  LYMPHATICS  are  very  numerous  and  communicate  with  the 
axillary  lymphatic  glands.  The  nerves  come  from  the  cervical 
plexus  and  the  fourth,  fifth  and  sixth  intercostal  nerves,  which 
are  accompanied  by  sympathetic  filaments. 

THE  FUNCTION  of  the  mammae  is  to  secrete  milk  for  the 
nourishment  of  the  child  for  the  first  twelve  months.*  They  have 
a  very  close  connection  with  the  pelvic  organs  so  that  disease  of 
one  affects  the  other.  Stimulation  of  the  nipples  produces  a  con- 
traction of  the  uterus  and  excites  sexual  desire.  Immediately 
following  labor  the  nursing  of  the  child  causes  an  increase  of  the 
lochia,  since  uterine  contraction  follows  the  stimulation  caused 
by  nursing;  and  on  this  account  the  child  should  be  placed  to 
the  breast  as  soon  as  possible  after  labor. 

The  size  of  the  gland  depends,  in  most  cases,  upon  the  amount 
of  sexual  irritation  and  the  age  at  which  puberty  appeared.     In 

THE     YOUNG,     very     LARGE     MAMMAE     denote    PRECOCIOUS   SEXUAL 

DEVELOPMENT.  This  development  or  early  puberty  follows  mas- 
turbation or  sexual  excitement  from  other  causes.  In  others 
the  glands  are  naturally  large.  If  there  is  atrophy  or  non-devel- 
opment, it  indicates  that  the  ovaries  are  not  very  active  and  that 


MISCELLANEOUS   AFFECTIONS.  505 

the  sexual  sense  is  not  ver}^  well  developed.  In  treating  such 
cases  attention  should  be  given  the  pelvic  organs  as  well  as  the 
RIBS  upon  which  the  glands  lie. 

DISEASES.  The  most  common  disease  found  is  some  en- 
largement or  tumor.  These  enlargements  are  usually  in  the 
lymphatic  glands,  but  are  occasionally  located  in  the  lactiferous 
glands. 

The  lymphatic  enlargements  occur  at  the  base.  At  first  it  is 
a  kernel  about  the  size  of  the  end  of  the  little  finger.  It  is  freely 
movable  and  slightly  tender  on  pressure;  enlarges  very  slowly,  if 
at  all,  and  if  it  is  very  hard  runs  a  chronic  course.  It  gives  rise 
to  no  physical  inconvenience,  but  to  a  great  deal  of  mental  anxiety. 
It  is  innocent  in  character  unless  worked  with  too  much  or 
briiised  by  manipulation  or  operations. 

A  rather  curious  thing  is  noted  in  many  cases  of  post-partum 
MASTITIS.  If  the  lochia  is  abnormal  in  any  way,  the  breasts  are 
IMMEDIATELY  AFFECTED;  and  I  believe  that  in  ninety  per  cent,  of 
all  cases  of  mastitis,  the  trouble  is,  to  a  great  extent,  ix  the 
uterus,  such  as  retention  of  a  part  of  the  placenta  or  lochial  dis- 
charge. In  some  there  is  a  partial  inversion  which  keeps  up 
an  irritation,  resulting  in  subinvolution  with  hemorrhage.  In 
one  case  of  mastitis  in  which  an  abscess  formed  in  the  breast, 
there  was  a  discharge  from  the  uterus.  It  was  of  a  greenish 
color,  and  when  it  was  lessened  the  discharge  from  the  breast  in- 
creased and  seemed  to  be  identical  in  composition  with  that  from 
the  uterus. 

The  treatment  for  mammary  diseases  in  general,  consists  of 
correcting  the  second,  third  and  fourth  ribs  so  as  to  permit  of  a 
free  lymphatic  circulation,  as  well  as  that  of  the  blood.  Treat- 
ments given  directly  to  the  enlargement  should  be  very  light  and 
I  doubt  if  the}'  are  ever  indicated.     Massage  of  an  inflamed  breast 


506  DISEASES   OF    WOMEN. 

for  the  purpose  of  emptying  it  of  retained  milk  is  helpful,  if  proper- 
ly performed. 

Sometimes  fibroid  tumors  are  found  in  the  gland.  They 
are  very  similar  to  an  enlarged  lymphatic  gland  but  are  harder, 
not  so  tender,  and  their  growth  less  rapid.  They  most  commonly 
follow  injuries  of  the  ribs,  strains  of  the  muscles,  traumatism  or 
direct  injuries  to  the  glands  or  muscles  in  that  region.  Their 
course  is  chronic,  growth  very  slow,  and  need  cause  little  alarm 
unless  bruised,  when  they  may  develop  into  malignant  tumors 
such  as  a  sarcoma  or  a  malignant  adenoma.  The  treatment  con- 
sists in  freeing  the  circulation  to  the  gland  and  of  gentle  manipu- 
lation to  the  tumor  itself.  Operations  should  be  avoided  if  possi- 
ble, since  the}'  often  excite  malignancy  on  account  of  the  injury 
to  the  tissues. 

CANCER  of  the  breast  is  usually  of  the  scirrhous  variety. 
It  is  found  in  the  glandular  substance  proper,  and  is  in  most  in- 
stances, the  result  of  bruising  of  the  gland.  This  bruising  may  be 
from  accident,  too  hard  a  treatment,  prolonged  nursing  or  an 
operation  whereby  the  gland  is  laid  open.  It  generally  begins 
in  SMALL  HARD  LUMPS  in  the  substance  of  the  breast.  Its  growth 
is  at  first  slow,  but  afterwards  rapid.  It  is  located  very  close 
to  the  nipple,  and  on  this  account  the  nipple  becomes  fixed  and 
RETRACTED.  The  skin  finally  gives  way  as  the  swelling  increases 
and  a  foul  ulcer  is  formed.  The  lymphatic  glands  become  in- 
volved and  are  swollen  and  tender.  The  movements  of  the 
shoulder  and  arm  are  hindered  since  the  pectoral  muscles  are 
affected.  Soon  in  a  bad  case,  the  constitutional  symptoms  of 
cancer  appear,  followed  by  death. 

The  diagnosis  is  based  upon  the  retraction  of  the  nipple,  indu- 
ration, rapid  progress  of  the  disease,  tenderness,  ulceration  and 
the  constitutional  symptoms.     A  great  many   cases  of  simple 


MISCELLANEOUS    AFFECTIONS.  507 

TUMORS  are  mistaken  for  malignant  or  made  malignant  by  op- 
eration. If  a  lump  is  found  in  the  breast  and  it  becomes  tender, 
an  operation  is  at  once  advised.  In  our  practice  we  have  cured  a 
majority  of  cases  of  supposed  cancer  by  correcting  a  displaced  rib 
or  ribs.  The  third  or  fourth  rib  is  usually  found  twisted,  pro- 
ducing tenderness  at  the  junction  of  the  ribs  with  the  costal  car- 
tilages, stagnation  of  the  lymphatic  and  venous  circulation  with 
engorgement  of  the  lymphatic  glands  both  in  the  mammae  and 
axilla.  A  retracted  nipple  may  result  from  ovarian  disease  or 
non-development  but  coupled  with  other  cancerous  indications, 
aids  in  making  up  the  diagnosis. 

TREATMENT.  The  surgical  treatment  is  extirpation  of  the 
gland  as  soon  as  possible.  The  osteopath  advises  removal,  if 
the  disease  does  not  3'ield  to  treatment  after  a  sufficient  trial 
has  been  given.  This  treatment  consists  in  correcting  displaced 
ribs,  the  most  common  being  the  second,  third  or  fourth,  and  in 
correcting  lesions  of  the  corresponding  vertebrae. 

The  symptoms  of  the  rib  displacements  are,  tenderness  at 
the  articulations  or  along  the  course  of  the  rib,  and  irregularities 
of  the  ribs  such  as  undue  prominence  of  one  of  the  edges  or  ends. 

Treatment  over  the  tumor  is  rarely  given  if  tenderness  is 
present,  since  it  increases  the  irritation  and  inflammation.  The 
PAIN  in  the  breast  is  most  commonly  in  an  intercostal  nerve  and 
by  raising  the  ribs  and  using  inhibition  at  the  vertebral  end,  it 
can  be  relieved.  Remember  in  mammary  affections  that  the  en- 
largement is  due  in  most  cases  to  swelling  of  the  lymphatic  glands 
or  a  subluxated  rib;  that  the  pain  is  intercostal  and  due  to  a  dis- 
turbance of  the  intercostal  nerve;  that  operations  can  be  avoided, 
hence  the  prevention  of  malignancy  in  a  great  many  cases;  and 
that  the  prognosis  is  good  in  most  mammary  affections.  If  the 
case  is  one  of  true  carcinoma  relief  can  be  given  but  a  cure  is  not 
probable. 


508  DISEASES    OF   WOMEN. 

CHLOROSIS  is  a  term  applied  to  an  anemic  condition  in 
young  girls  at  or  just  after  puberty,  which  is  the  result  of  impov- 
erished blood.  The  common  name  is  "green  sickness,"  so 
named  from  the  yellowish  green  color  of  the  complexion. 

The  causes  are  hygienic,  dietetic  and  lesions.  Girls  who 
are  closely  confined  to  a  stuffy  room,  ill-fed,  over-worked  . 
and  who  take  little  or  no  exercise  in  the  open  air,  are  the  ones 
most  likely  to  be  attacked.  If  the  patient  is  approaching,  or  has 
just  passed  puberty,  the  greater  the  likelihood  of  the  disease  devel- 
oping. Although  such  environment  and  poor  food  tend  to  bring 
on  the  disease,  back  of  it  all  are  lesions  affecting  the  nutrition 
of  the  body.  These  lesions  are  most  frequently  found  in  the 
third,  fourth  and  fifth  thoracic  vertebrae.  The  spine  is  flattened 
at  these  points,  affecting  the  lungs  and  heart,  the  two  impor- 
tant organs  which  have  to  do  with  the  quality  of  the  blood  and 
its  circulation.  The  heart  is  affected  in  these  cases,  being  weak 
and  irritable.  The  quality  of  the  blood  is  impaired,  there  being 
an  anemic  state,  the  red  corpuscles  being  lessened  in  number  and 
deficient  in  hemoglobin,  hence  nutrition  suffers.  On  account  of 
the  blood  changes  the  complexion  is  peculiar,  in  that  it  has  a 
yellowish  green  tinge.  The  patient  tires  easily  on  exertion, 
there  being  shortness  of  breath  and  palpitation  of  the  heart.  The 
PULSE  is  accelerated  and  easily  compressed.  Digestion  is  im- 
paired and  the  patient  often  has  a  depraved  appetite,  such  as  a 
desire  for  crayon,  slate  pencils,  etc.  The  bowels  are  sluggish; 
in  fact,  the  entire  gastro-intestinal  tract  is  impaired,  this  being 
one  of  the  complications  of  poor  nutrition  and  assimilation. 

Menstrual  disturbances  are  common,  amenorrhea  being  the 
usual  form.  In  a  small  per  cent,  of  cases  menorrhagia  is  present. 
It  seems  that  the  blood  loses  its  power  to  coagulate,  hence  when 
the  flow  once  starts,  it  continues  longer  than  the  normal,  since 


MISCELLANEOUS    AFFECTIOXS.  509 

an  internal  clot  forms  with  difficulty,  the  formation  of  such  a 
clot  being  nature's  method  of  checking  an}'  hemorrhage.  The 
EYEBALLS  usuallv  have  a  pearly  or  bluish  tint  sometimes  quite 
noticeable. 

The  treatment  from  a  medical  standpoint  is  the  giving  of 
iron  in  some  form.  Many  claim  it  to  be  a  specific,  yet  one  writer 
says  that  "the  body  can  get  more  iron  out  of  a  cabbage  leaf 
THAN  FROM  A  SPOONFUL  OF  THE  DRUG."  The  osteopath  believes 
in  giving  iron,  but  in  the  form  of  fruits,  etc.,  the  highly  colored 
fruits  containing  an  abundance  of  iron  m  a  form  that  can  be 
assimilated*.  Good  air,  exercise  and  deep  breathing  are  almost  es- 
sential in  the  treatment  of  chlorosis  if  good  results  are  expected. 
These  coupled  with  the  correction  of  the  spinal  lesions  mentioned 
above  will  cure  in  95  per  cent,  of  cases.  On  account  of  the  weak- 
ness of  the  abdominal  wall  and  the  frequency  of  enteroptosis, 
lifting  up  treatments  should  be  applied  to  the  abdomen.  This  is 
of  assistance  in  relieving  the  constipation  and  promoting  assimi- 
lation. 

LACK  OF  ORGASM.  Orgasm  is  the  "crisis  of  venereal 
passion."  The  writer's  apology  for  discussing  this  subject  is 
the  fact  that  there  are  so  many  cases  in  which  the  sexual  passion 
IS  diminished  OR  ENTIRELY  lost,  thus  making  the  sexual  act  pos- 
itively repugnant.  Such  conditions  give  rise  to  conjugal  unhap- 
piness  and  many  a  divorce  proceeding  has  for  its  real  cause  some 
disorder  like  the  above. 

Orgasm  depends  upon  a  healthy  condition  of  the  pudic 
nerve.  There  must  be  erection  of  parts,  that  is  of  clitoris,  va- 
gina and  lesser  lips,  and  a  sensory  nerve  connecting  parts  with  the 
center  in  the  spinal  cord  and  brain.  The  pudic  nerve  ends  in 
the  clitoris  and  is  the  sensory  nerve  by  which  the  impulses  are 
carried  to  the  spinal  cord.     Anything  impairing  the  function 


510  DISEASES    OF    WOMEN. 

OF  THIS  NERVE,  that  Is  peripherally  or  along  its  course,  or  a 
diseased  condition  of  the  spinal  cord,  thus  interfering  with  the 
reception  of  the  impulses  will  thus  interfere  with  orgasm. 

The  MOST  important  of  all  causes  is  a  diseased  condition 
of  the  cells  in  the  spinal  cord.  They  are  in  such  a  condition 
that  they  do  not  receive  impulses  carried  to  them  over  the  pudic 
nerve.  This  may  be  the  result  of  an  error  in  development.  The 
writer  has  one  patient,  one  of  twins,  in  which  these  cells  were 
never  developed,  at  least  the  parts  remain  perfectly  passive  dur- 
ing coitus,  there  being  no  indication  of  sexual  passion.  Most 
cases  come  from  lesions  affecting  the  cells  of  origin  of  the  pudic 
nerve,  ranging  from  the  tenth  dorsal  to  the  fourth  lumbar  verte- 
bra, or  from  sexual  abuses  such  as  excesses.  The  most  common 
lesion  is  found  in  the  lower  thoracic  region. 

The  symptoms  consist  of  a  perversion  of  the  sexual  act  in 
which  voluptuous  sensation  is  lessened  or  entirely  lost.  Steril- 
ity, atrophy  of  the  ovaries  and  a  lessening  of  the  vaginal  secre- 
tions complicate.  Menstrual  disturbances  are  often  found,  such 
as  amenorrhea  and  delayed  menstruation.  The  general  effects 
are  often  marked,  the  most  important  being  despondency  and 
nervousness.  The  patient  looks  on  the  dark  side  of  things,  has 
the  "blues"  and  is  in  an  unsatisfied,  restless  condition.  Most 
of  the  time  the  marital  relations  are  unsatisfactory  and  often 
separation  follows. 

In  the  acquired  cases,  cures  have  been  performed  by  cor- 
recting the  spinal  cord  disturbance.  This  was  accomplished 
by  securing  good,  normal  circulation  to  and  from  the  spinal  cord 
and  relieving  the  pressure  on  the  pudic  nerve.  These  things 
are  accomplished  by  adjusting  the  spine,  there  being  lesions 
which  are  responsible.  Sexual  rest  must  be  secured  or  at  least 
the  function  properly  regulated. 


MISCELLANEOUS    AFFECTIONS.  511 

In  the  congenital  form  little  or  nothing  can  be  done,  at  least 
i;he  writer  has  failed  in  such  cases.  The  subject  is  one  of  vital 
importance  since  so  much  mental  suffering  is  entailed  by  it. 

SCIATICA  complicating  uterine  disease,  is  very  important 
although  not  noted  or  treated  in  the  vast  majority  of  cases. 
Sciatica  is  a  painful  condition  of  the  great  sciatic  nerve  due  to 
congestion  or  inflammation  of  the  nerve.  In  the  mild  types 
ONLY  CONGESTION  exists,  but  in  the  more  aggravated  types  a 
true  neuritis  is  present. 

The  causes  of  sciatica  in  the  female  can  be  included  under 
two  heads;  inflammation  of  the  uterus  or  its  adnexa,  or 
PRESSURE  on  the  roots  of  the  nerve;  and  a  lesion  of  one  or  more 
of  the  BONES  FORMING  the  PELVIS,  most  frequently  a  backward 
twist  of  the  innominate  bone  on  the  affected  side.     I  believe 

THAT  A  MILD  TYPE  OF  SCI.\TICA  COMPLICATES  EVERY  CASE  OF  ME- 
TRITIS. There  are  several  explanations  for  this:  one  is  that  the 
VENOUS  DRAINAGE  of  the  iierve  is  affected  by  a  stagnation  of  the 
blood  in  the  pelvis  and  this  condition  is  always  present  in  metritis. 
The  blood  is  forced  back  along  the  veins,  the  nerve  congests,  the 
vascular  pressure  is  thereby  increased  and  pain  follows;  yet  in 
most  cases  this  pain  does  not  occur  except  on  artificial  pressure, 
whereby  the  vascular  pressure  is  increased.  The  nervous  con- 
nection furnishes  another  explanation.  The  same  seg.ment 
of  the  cord  which  gives  origin  to  the  great  sciatic  nervk,  con- 
tains the  CENTER  for  the  nerves  of  the  uterus.  A  stimulus 
applied  at  the  visceral  end  will  cause  an  effect,  motor  or  sensory 
or  both,  in  the  posterior  or  in  the  other  anterior  branches.  Possi- 
bly Head's  law  will  best  explain  the  secondary  disease.  The 
same  lesion  will  produce  both  diseases;  that  is,  uterine  dis- 
turbances and  sciatica.  This  to  the  osteopath  is  the  most  plausi- 
.  ble,  since  few  vascular  diseases,  and  I  mean  congestion   and  in- 


512  DISEASES    OF    WOMEN. 

flammation  of  the  female  genitalia,  are  not  caused  or  exaggerated 
by  some  lesion  of  the  bony  pelvis.  This,  therefore,  leads  us  to 
the  most  important  cause  of  sciatica  in  women,  viz:  a  subluxa- 
tion OF  THE  INNOMINATE.  The  particular  type  of  lesion  is  a 
BACKWARD  ROTATION  which  is  the  most  common  of  all  innomi- 
nate lesions,  for  reasons  named  later.  This  lesion  affects  the 
sciatic  nerve  since  it  is  in  relation  with  its  roots  and  course.  This 
lesion  affects  the  vaso-motor  nerves  of  the  sciatic  nerve  and  the 
uterus,  thereby  causing  vascular  disturbances  in  both.  Also  as 
stated  above,  the  lesion  is  responsible  for  both  the  uterine  dis- 
ease and  the  sciatica,  hence  it  is  not  a  purely  reflex  disturbance 
as  it  is  supposed  by  many  to  be. 

Some  cases  of  sciatica  are  due  to  pressure  of  an  inflamed 
UTERUS  on  the  roots  of  the  sciatic  nerve.  One  of  the  worst  cases 
ever  treated  by  the  author  was  due  to  a  retroflexed  uterus  which 
had  adhered  to  the  nerve.  The  ordinary  treatments  had  little 
effect  and  an  operation  was  advised.  Abdominal  fixation  was 
performed,  which  resulted  in  a  cure. 

The  indications  of  sciatica  are  pain  or  ache  along  the  course 
of  the  nerve,  being  most  intense  at  points  at  which  the  nerve  is 
most  superficial,  coldness  of  limb,  cramping  of  hip  or  limb 
and  distinct  tenderness  on  pressure  at  a  point  midway  between 
the  TUBEROSITY  of  the  ISCHIUM  and  the  great  trochanter. 
The  author  makes  it  a  routine  practice  in  the  examination  of  all 
cases  of  female  disease  to  make  this  test;  that  is,  pressure  over 
the  nerve  at  the  above  mentioned  point.  When  sciatica  is 
thus  diagnosed,  a  better  explanation  of  limb  disturbances  is 
furnished. 

The  treatment  consists  in  correcting  the  bony  and  visceral 
lesions,  viz:  the  luxated  innominate  and  the  uterine  displace- 
ment, or  if  these  do  not  exist,  relieve  the  pelvic  congestion  or 
inflammation. 


MISCELLANEOUS   AFFECTIONS.  513. 

EYE  STRAIN  or  severe  aching  of  the  eyes  is  often  associated 
with  uterine  disease.  The  pain  is  either  in  the  ball  of,  or  just 
immediately  above,  the  eye.  There  is  usually  an  error  in  re- 
fraction as  the  predisposing  cause.  The  pain  is  a  great  deal 
worse  during  the  menstrual  period.  I  recently  had  a  case  in 
which  the  ache  could  not  be  relieved  by  the  ordinary  neck  treat- 
ment, but  when  the  uterine  displacement  was  corrected,  the  pain 
instantly  left.  The  seat  of  the  pain  is  in  the  fifth  cranial  nerve, 
the  reason  being  that  it  has  such  a  close  connection  with  the 
SYMPATHETIC  SYSTEM  by  the  numorous  sympathetic  ganglia  sit- 
uated upon  it. 

PIGMENTATION  of  the  skin  is  sometimes  found  as  a  result  of 
female  disease.  I  treated  a  case  of  retroflexion  of  the  uterus, 
with  irregular  or  delayed  menses,  in  which  pigmented  spots 
about  an  inch  in  diameter  would  appear  in  crops  on  the  chest 
and  neck.  These  spots  are  usually  called  liver  spots  and  are 
attributed  to  some  liver  disturbance.  The  liver  is  usually  to 
blame,  but  not  always,  since  I  have  cured  man}'  cases  by  relieving 
the  pelvic  disturbances.  In  some  cases  of  uterine  disease  a  diffuse 
pigmentation  occurs,  assuming  the  form  of  a  pasty,  dirty  brown 
color.  The  complexion  is  very  sallow  and  cadaverous;  the  skin 
appearing  to   be   dead.     This    form   of   pigmentation   occurs 

especially    in    DEGENERATIVE    DISEASES    OF    THE    OVARIES,    SUch 

as  CYSTIC  DEGENERATION.     It  also  occurs  in  renal  and   capsular 
diseases. 

LEUCODERMIA  is  in  some  cases  due  to  pelvic  disease.  The 
writer  has  treated  and  seen  cases  treated  of  this  kind  in  which 
there  were  irregular  white  patches  covering  the  entire  body.  In 
most  of  these  cases  uterine  disease  was  present  and  when  corrected 
the  white  patches  disappeared.  The  most  common  form  of 
uterine  disease  was  metritis  complicated    by  displacement  and 

33 


5t4  DISEASES    OF    WOMEN. 

menstrual  irregularities.  Leucodermia  occasionally  appears  in 
the  male. 

During  pregnancy  yellowish  brown  spots  appear  on  the  face 
and  neck,  sometimes  on  other  parts  of  the  body.  Also  they 
accompany  uterine  polypi  if  symptoms  of  pregnancy  are  pres- 
ent. The  pigmentation  will  disappear  and  the  skin  regain  its 
natural  color  if  uterine  and  liver  troubles  are  corrected. 

CHRONIC  INGUINAL  AND  FEMORAL  HERNIA  are  occas- 
ionally met  with  in  the  female,  though  not  so  commonly,  as  in 
the  male.  If  the  opening  is  small  and  the  bowel  stays  up  pretty 
well,  and  the  patient  keeps  off  her  feet  and  avoids  straining  her- 
self, the  outlook  for  a  cure  is  fairly  good  if  osteopathic  treatment 
is  given.  By  lifting  the  bowel  and  developing  the  abdominal 
muscles  by  certain  well  directed  exercises  coupled  with  some 
manipulation  applied  to  the  affected  part,  at  least  relief  if  not  a 
cure  can  be  effected.  If  the  bowel  comes  down  often,  a  properly" 
fitted  truss  should  be  worn. 

Hernia  of  the  partial  variety  may  come  on  suddenly  and  pro- 
duce symptoms  of  appendicitis  and  various  other  acute  intes- 
tinal diseases.  It  consists  of  the  bowel  being  forced  partly 
THROUGH  the  internal  abdominal  ring  or  through  the  omentum. 
It  follows  strains  or  vigorous  muscular  actions  and  its  onset  is 
very  sudden.  The  pain  is  very  acute  and  cramp-like.  If  on  the 
right  side  it  may  be  mistaken  for  acute  appendicitis  or  ovarian 
disease,  since  the  pain  radiates  upward  and  is  localized  in  many 
cases  at  or  near  McBumey's  point.  On  palpation  the  tumor 
can  be  felt  at  the  abdominal  ring  and  is  very  sensitive  on  pressure. 
The  ovary  may  be  implicated  and  the  pain  reflected  to  the  back 
by  way  of  the  ovarian  plexus.  In  either  case  the  patient  should 
be  placed  in  the  Trendelenburg  position  and  the  intestines  lifted 
out  of  the  pelvis.     By  a  deep  gentle  manipulation  of  the  abdomen 


MISCELLANEOUS   AFFECTIONS.  515 

■with  an  upward  motion  this  can  be  accomplished  and  the  patient 
instantly  relieved. 

PHLEGMASIA  ALBA  DOLENS,  or  what  is  commonly  called 
^'milk  leg/'  is  a  disease  which  follows  parturition.  The  acute 
form  is  supposed  to  be  the  result  of  septic  infection.  The  in- 
fection takes  place  primarily  in  the  uterus  and  extends  to  the 
femoral  vein,  resulting  in  an  inflammation  or  phlebitis.  This 
results  in  venous  obstruction  and  enormous  swelling  of  the  affected 
leg.  The  disease  was  formerly  supposed  to  be  due  to  metastasis 
of  milk. 

The  acute  form  starts  with  a  chill  followed  by  fever  and 
painful  swelling  of  the  leg.  This  swelling  takes  place  in  most 
<'ases  from  below  up  and  is  characterized  by  a  red  line  along  the 
course  of  the  femoral  vein  and  by  such  a  tenseness  that  the 
skin  does  not  pit  on  pressure. 

In  cases  that  do  not  terminate  fatally,  the  disease  runs  a 
■chronic  course  and  it  is  this  form  that  comes  within  the  scope  of 
this  work.  The  chronic  form  is  characterized  by  atrophy,  weak- 
ening and  loss  of  sensibility  in  the  affected  limb;  the  limb  seems 
to  be  dead  and  is  cold  a  great  deal  of  the  time.  In  some  the 
limb  is  strong  enough  to  permit  standing  and  walking,  in  others 
the  paralysis  is  complete.  The  chalky,  atrophied  appearance 
plus  the  history  of  an  attack  in  the  limb  as  a  sequel  to  labor 
make  the  diagnosis  unquestioned. 

As  stated  above,  the  supposed  cause  of  "milk  leg"  is  septic 
infection.  The  writer  believes  this  to  be  a  mistake  and  would 
beg  leave  to  substitute  trauma  as  a  cause  of  the  disease.  The 
form  of  trauma  is  an  injury  of  the  lumbar  vertebrae,  or  of  the 
innominate  bone.  During  pregnancy  all  these  joints  become 
more  movable,  this  acting  as  a  predisposition  to  a  luxation  of 
■either  a  vertebra  or  the  innominate.     During  labor  the  extreme 


516  DISEASES    OF    WOMEN. 

AMOUNT  OF  FORCE  brought  to  bear  on  these  parts  sometimes  re- 
sults in  a  luxation.  The  most  common  lesion  is  a  strain  or  slip 
of  one  of  the  innominate  bones.  This  is  true  in  cases  in  which 
the  limbs  are  extremely  flexed  on  the  abdomen.  In  the  few 
cases  of  milk  leg  the  writer  has  seen  (the  careful  osteopathic 
obstetrician  prevents  the  disease)  the  above  mentioned  lesion 
was  found  and  when  corrected  the  patient  recovered.  In  all 
chronic  cases,  and  we  see  many,  an  innominate  or  hip  lp:sion 
WAS  found  in  every  one.  If  the  case  is  not  too  chronic  the 
prognosis  is  favorable,  but  if  very  chronic  it,  like  all  chronic 
cases  of  long  standing,  is  hard  to  cure.  Also  the  degree  of  atrophy 
and  weakness  must  be  considered  when  making  up  the  prognosis. 

The  treatment  is  the  osteopathic  one  directed  to  the  correc- 
tion of  the  above  mentioned  lesions.  The  prophylactic  treatment 
consists  of  a  thorough  examination  of  the  hips  and  innom- 
I  NATES  at  the  conclusion  of  labor,  and  adjusting  any  displace- 
ment found.  The  author  usually  rotates  the  hips  immediately 
after  labor  if  patient  complains  of  any  pain  or  cramping  in  the 
limbs. 

In  chronic  cases  a  subinvoluted  uterus  may  be  present 
which  aggravates  the  condition  and  must  be  corrected  before  a 
complete  cure  is  effected. 

DISEASES  OF  THE  KNEE  AND  FOOT  often  complicate 
pelvic  disturbances.  Synovitis  of  the  knee  joint  is  the  most  com- 
mon. There  is  at  first  a  slight  swelling  around  the  joint,  usually 
described  as  a  "puffy"  condition,  coupled  with  some  tenderness 
and  stiffness.  The  swelling  increases  until  the  knee  is  very  much 
enlarged,  which  is  attended  by  the  usual  symptoms  of  inflamma- 
tion. 

On  local  vaginal  examination,  in  many  of  these  cases,  an 
inflamed  or  prolapsed  ovary  was  found  on  the  same  side.  These  con- 


MISCELLANEOUS   AFFECTIONS.  517 

ditions  were  accompanied  by  a  uterine  displacement,  it  being 
back  and  down.  The  correction  of  the  pelvic  disturbances  cured 
all  these  cases  in  which  the  synovitis  was  secondary.  Usually 
a  twisted  condition  of  the  innominate  is  responsible  for  both  the 
pelvic  disease  and  synovitis  of  the  the  knee  and  deserves  first  at- 
tention. After  the  correction  of  the  bony  lesions,  replacement 
of  the  prolapsed  viscera  will  result  in  a  complete  cure. 

THE  ERUPTIONS  OF  THE  SKIN  in  female  diseases  occur 
most  frequently  as  a  complication  of  menstrual  disorders.  The 
most  common,  as  well  as  harmless,  is,  in  many  women,  the  her- 
petic ERUPTION  on  the  lip  at  each  menstrual  period.  In  others 
acne,  in  a  chronic  form  furnishes  a  very  undesirable  eruption  and 
one  for  which  all  kinds  of  cosmetics  are  used.  It  is  worse  at  each 
menstrual  period;  and  at  puberty  is  often  very  bad  on  account 
of  the  increase  in  amount  of  inflammation,  giving  the  face  a 
mottled  appearance.  The  sebaceous  glands  fail  to  perform  their 
function  and  there  is  a  retention  of  the  secretions,  giving  rise  to 
irritation  and  inflammation.  In  such  cases  perspiration  in  the 
affected  region  is  stopped,  the  part  appearing  oily,  or  as  the  pa- 
tient often  expresses  it  "greasy." 

An  IMPERFECT  EMPTYING  of  the  uterus  at  the  menstrual 
period  is  given  as  a  cause.  The  general  change  in  the  blood  at 
the  menstrual  period,  it  becoming  impoverished,  is  a  better  cause. 
The  patient  is  anemic  and  mal-nourished,  which  condition  is 
perhaps  a  cause  rather  than  an  effect.  Masturbation  and  ex- 
cessive VENERY  are  also  mentioned  as  causes,  or  rather  such 
conditions  are  associated.  In  some  cases  this  is  true,  that  is  mas- 
turbation is  the  underlying  cause,  but  eruptions  on  the  face  are 
not  necessarily  diagnostic  of  masturbation.  There  is  some  re- 
lation between  the  genitalia  and  skin  of  the  face  and  back,  and 
in  a  vast  majority  of  cases  a  diseased  or  perverted  condition  of 


518  DISEASES    OF    WOMEN. 

the  genitalia  exists  if  there  are  eruptions  on  face  and  back. 

The  treatment  consists  primarily  in  correcting  the  pelvic 
DISTURBANCES,  if  any  exist,  and  some  local  treatment  to  face 
and  neck.  The  pelvic  trouble  is  usually  a  menstrual  one  such  as 
retention  of  or  scanty  menses ;  in  others,  pathological  congestions 
with  hypersecretions,  which  weaken  the  body  by  impairing  the 
blood.  The  correction  of  cervical  lesions  is  important  since 
the  vaso-motor  supply  to  the  face  is  affected  by  such.  Pimples 
follow  localized  stagnation  and  putrefaction  of  blood.  A  toxic 
condition  from  other  causes  produces  inflammation  and  pus  forma- 
tion, therefore  to  cure  facial  eruptions  improve  the  quality  of 
the  blood  and  secure  good  circulation  through  the  face. 

A  MOLE  OF  THE  UTERUS  is  defined  as  a  tumor  resulting 
from  death  of  the  embryo  with  proliferation  of  the  cells  of  the 
deciduae.  In  missed  abortion  the  placenta  or  chorion  may  con- 
tinue to  develop,  or  at  least  not  loosen  and  become  expelled.  The 
embryo  is  absorbed  and  soon  a  fleshy  mass  is  formed  in  utero. 
The  cause  possibly  lies  in  a  diseased  endometrium. 

The  most  important  symptom  is  hemorrhage  and  pain. 
The  flooding  occurs  at  irregular  intervals  and  is  often  marked, 
leaving  the  patient  weak,  anemic  and  very  much  exhausted. 
On  local  examination  the  uterus  is  found  to  be  symmetrically 
enlarged;  that  is,  the  patient  appears  to  be  pregnant,  judging 
from  the  shape,  tone  and  position  of  the  uterus.  During  the  at- 
tack a  part  of  the  mass,  which  resembles  placental  tissue,  is  ex- 
pelled. At  this  time  the  patient  appears  to  be  in  hard  labor  and 
in  the  cases  seen  by  the  author,  the  pains  were  a  great  deal  worse 
than  in  an  ordinary  labor  case.  These  uterine  contractions  keep 
up  until  the  mole  is  expelled,  this  taking  quite  a  while  and  usually 
requires  assistance  in  the  form  of  the  application  of  abortion  for- 
ceps or  curettement.     If  all  the  growth  is  not  removed  it  will 


MISCELLANEOUS    AFFECTIONS.  519 

continue  to  enlarge  and  the  patient  has  another  "spell."  If  the 
uterus  is  entirely  emptied  of  this  flesh-like  growth  it  seldom 
returns. 

The  TREATMENT,  therefore,  consists  of  emptying  the  uterus 
of  this  mass  which  can  best  be  accomplished  by  the  use  of  the 
dull  curette. 

In  diagnosing   this  condition  remember  that  most  of  the 

EARLY    indications    OF    PREGNANCY    ARE    PRESENT,    which    things 

are  of  assistance  in  differentiating  it  from  subinvolution  and 
fibroid  tumors  of  the  uterus. 

There  is  a  rare  form  called  false  mole,  which  is  not  depend- 
ent on  pregnancy.  This  form  is  derived  from  fibroid  tumor, 
endometritis,  in  which  there  is  a  desquamated  cast  of  the  mucous 
membrane,  or  retained  coagula  of  menstrual  blood.  The  treat- 
ment is  about  the  same  in  all  forms,  viz:  securing  expulsion.  In 
the  false  form,  resort  is  seldom  made  to  the  use  of  instruments, 
the  tumor  being  expelled  by  securing  contraction  of  the  uterus. 

LEUCORRHEA  IX  CHILDREN  occasionally  occurs.  It, 
like  the  adult  form,  is  caused  by  congestion  of  the  vagina  or 
uterus,  usually  the  former,  There  are  two  causes  responsible 
for  the  cases  treated  by  the  WTiter,  viz:  lesions  along  the  lower 
thoracic  and  upper  lumbar  spine,  and  specific  infection  setting 
up  a  catarrhal  condition  of  the  vaginal  mucous  membrane. 

The  diagnosis  is  based  on  the  lesions  found  and  the  micro- 
scopical examination.  A  cure  can  be  effected  in  nearly  every 
case  produced  by  the  first  named  cause.  This  is  accomplished 
by  correcting  the  spinal  lesion.  The  cases  belonging  to  the  sec- 
ond named  cause  are  diagnosed  by  finding  the  gonococci  in  the 
discharge;  and  treated  by  applying  antiseptic  solutions  to  the 
diseased  area.     (See  specific  vaginitis.) 


520  DISEASES    OF    WOMEN. 

DISEASES  OF  THE  RECTUM  AND  ANUS.  A  great  many 
diseases  of  the  rectum  and  anus  in  the  female  are  secondary  to 
pelvic  disorders.  This  is  explained  by  the  proximity  of  the 
BOWEL  with  its  nerves  and  blood  vessels,  to  the  uterus  and  its 
adnexa. 

The  rectum  commences  at  the  sacro-iliac  synchondrosis 
with  which  it  is  in  close  relation,  crosses  to  the  middle  of  the  sac- 
rum, sometimes  past  the  median  line,  and  then  passes  down  be- 
tween the  sacro-uterine  ligaments  to  the  uterus.  The  upper  part 
is  invested  with  peritoneum  while  the  lower  part  is  not,  it  being 
in  direct  relation  with  the  vagina  anteriorly, and  the  coccyx  and 
levator  ani  posteriorly.  The  upper  part  of  the  rectum  is  in  rela- 
tion with  the  cervix  uteri  and  with  the  body  and  fundus  when  the 
uterus  is  retro-deviated,  hence  the  importance  of  examining  for 
uterine  trouble  in  cases  of  disturbance  of  this  part  of  the  bowel. 
The  rectu  m  is  drained  by  the  hemorrhoidal  plexus  of  veins.  This 
plexus  anastomoses  with  the  other  plexuses  in  the  pelvis.  The 
blood  vessels  that  drain  the  rectum  drain  the  uterus;  and  the 
nerve  plexus  that  supplies  the  one,  sends  filaments  to  the  other. 
This  furnishes  another  explanation  for  diseases  of  the  rectum  com- 
plicating uterine  disease. 

The  anus  is  the  external  aperture  of  the  intestine.  The 
orifice  is  surrounded  by  integment  puckered  into  folds,  which  is 
the  result  of  contraction  of  the  sphincter  muscles.  The  lining 
of  this  portion  of  the  intestinal  tract  is  smooth  and  is  subject  to 
relaxation  and  prolapsus.  The  principal  thing  to  remember  re- 
garding the  anus  is  that  the  anal  branch  of  the  pudic  nerve 
SUPPLIES  THE  L3Wf::i  PART,  hsuce  the  sexual  derangements  fol-- 
lowing  diseases  of  the  anus. 

The  injuries  of  the  rectum,  except  those  from  direct  trauma 
as  in  falling  on  a  sharp  object,  come  almost  entirely  from  parturi- 


MISCELLANEOUS    AFFECTIONS.  521 

tion.  Laceration  of  the  perineum,  pressure  on  the  bowel  by  the 
descending  head  of  the  fetus  resulting  in  eversion  of  the  anus, 
and  over  stretching  of  the  posterior  vaginal  wall  which  results  in 
rectocele  are  the  common  injuries  from  childbirth.  Complete 
laceration  of  the  perineal  body  is  the  worst  form  of  injury  and 
results  in  marked  disturbance  of  function  of  the  rectum,  vagina, 
uterus  and  pelvic  floor.  Infection  is  likely  to  occur  unless  the 
parts  are  kept  very  clean,  there  being  an  unprotected  point  at 
which  the  germs  make  their  attack. 

Fissure  of  the  anus  sometimes  complicates  retro-displace- 
ment of  the  uterus.  The  pressure  of  the  uterus  on  the  bowel 
affects  the  circulation  of  blood  through  it.  This  also  causes 
chronic  constipation  which  is  the  important  cause  of  fissure.  The 
hard  fecal  matter  passing  over  the  delicate  mucous  membrane 
of  the  bowel  results  in  injury  to  it,  such  as  erosion  or  tears  of  the 
mucous  tissue. 

Pain  is  the  most  constant  symptom  of  anal  fissure  and  varies 
with  the  severity  of  the  case.  In  some  the  pain  is  constant,  the 
patient  with  difficulty  finding  a  position  of  ease.  It  is  not  con- 
fined to  the  anus  but  radiates  to  the  lower  limbs  and  lumbar  re- 
gion. In  all  cases  the  pain  is  necessarily  worst  during  defeca- 
tion. 

The  diagnosis  is  based  on  inspection,  the  fissure  usually  being 
low  enough  to  be  readily  seen.  In  straining  at  stool  blood  is 
often  discharged  and  the  anal  mucous  membrane  everted.  On 
local  vaginal  examination,  the  body  of  the  uterus  is  found  to  be 
in  many  cases,  low  down  and  back  against  the  bowel. 

The  treatment  consists  of  correction  of  the  uterine  displace- 
ment, adjusting  the  coccyx  and  sacrum  and  relieving  the  con- 
stipation. 

Proctitis  and  rectal  abscesses  often,  like  fissure,  come  from 
pressure  of  a  retro-displaced  uterus. 


522 


DISEASES    OF    WOMEN. 


STRICTUKE  also  comes  from  a  similar  cause.  At  first  it  is 
temporary,  that  is  the  uterus  obstructs  the  bowel ;  later  an  irrita- 
tion is  set  up,  perhaps  abscesses  form,  and  the  scar  tissue  result- 
ing, produces  a  permanent  stricture.  The  writer  has  seen 
temporary  stricture  complicate  anteversion  with  a  backward 
slipping  of  the  uterus,  thus  forcing  the  cervix  into  the  bowel, 
obliterating  its  lumen.     Chronic  constipation  results  in  such  cases. 

FIstulae  in  ano  complicate  pelvic  diseases  in  many  instances. 
A  fistula,  meaning  a  pipe,  is  defined  as  "an  abnormal,  tube-like 
passage  in  the  body"  and  when  applied  to  the  anus  is  an  abnormal 
channel  of  communication  between  the  bowel  and  the  surface  in 
the  neighborhood  of  the  anus.     This  channel  is  formed  by  the 


Fig.  109 — Showing  different  forms  of  rectal  fistulae,  (diagrammatic). 

efforts  of  pus  to  escape  from  a  pus  cavity.  The  pus  cavity  is 
the  result  of  decomposed  blood;  that  is,  the  blood  dies  from  lack 
of  movement  and  pus  formation  begins.  This  stagnation  of  the 
blood  comes  oftenest  from  pressure  and  in  the  female,  from  a  retro- 


MISCELLANEOUS   AFFECTIONS.  523 

displaced  uterus  pressing  on  the  blood  vessels  of  the  tissues  in 
and  around  the  bowel. 

There  are  three  forms  of  fistulae;  the  complete,  in 
which  there  is  a  continuous  sinus  with  an  opening  upon  the  mu- 
cous membrane  and  another  externally;  the  blind  internal, 
in  which  there  is  no  external  opening;  and  the  blind  external, 
in  which  there  is  no  connection  with  the  bowel.  The  form  is 
determined  by  the  amount  and  location  of  pus  and  the  direction 
in  which  it  burrows. 

In  some  patients  the  symptoms  are  marked;  in  others,  un- 
important. Pruritus  with  some  inflammation  at  the  orifice  are 
common.  The  diagnosis  is  based  on  locating  the  opening  from 
which  pus  is  discharged.  The  extent  can  only  be  determined  by 
the  use  of  a  probe.  In  blind  internal  fistulae,  the  pus  is  expelled 
per  rectum  and  the  opening  located  with  difficulty. 

The  treatment  consists  in  restoring  normal  drainage  of  the 
diseased  area,  which  is  accomplished  by  replacing  the  uterus, 
thus  removing  the  pressure  on  the  blood  vessels.  This  coupled 
with  adjustment  of  the  sacro-coccygeal  and  sacro-iliac  articula- 
tions will  cure  without  an  operation.  In  rare  cases  an  operation 
is  advisable. 

HEMORRHOIDS.  On  account  of  the  frequency  of  hemor- 
rhoids in  the  female  and  their  association  with  female  diseases, 
a  short  description  will  not  be  amiss  at  this  place. 

A  hemorrhoid  is  a  vascular  tumor  produced  by  a  chronic 
distention  of  the  hemorrhoidal  plexus  of  veins.  This  distention 
is  due  to  vaso-motor  paralysis  or  a  mechanical  obstruction  of 
the  vein.  The  latter  is  more  common.  This  obstruction  is 
usually  a  retro-displaced  uterus,  and  in  every  case  of  hemor- 
rhoids in  the  female,  I  would  examine  the  uterus  for  a  displace- 
ment or  enlargement.     A  slipped  innominate  or  chronic  consti- 


524 


DISEASES    OF    WOMEN. 


patioii  in  which  there  is  impaction  of  the  bowel,  frequently  im- 
pedes the  return  flow  and  causes  distention  of  these  veins.  Dur- 
ing pregnancy  they  are  increased  in  size.     If  enemata  are  used 


Fig.  110. — Showing  veins  in  hemorrhoid.s,  (diagrammatic). 

very  often  while  the  bowel  is  impacted,  as  is  the  case  in  chronic 
constipation,  the  engorged  blood  vessels  will  be  forced  down 
and  become  enlarged,  causing  exquisite  pain  and  agony  until 
replaced  and  the  blood  pressure  in  these  veins  lowered. 

Chronic  liver  troubles  also  tend  to  produce  hemorrhoids. 

In  TREATING  hemorrhoids,  look  for  the  obstruction,  whether 
in  the  bowels,  liver,  uterus  or  whether  it  is  due  to  muscular  con- 
tractions, and  remove  it.  A  local  rectal  treatment  is  occasionally 
given  whereby  the  mucous  membrane  of  the  bowel  can  be  par- 
tially relieved  of  its  stagnated  blood.  If  the  hemorrhoid  is  a  vas- 


MISCELLANEOUS    AFFECTIONS.  525 

cuLAR  ONE  and  is  external  it  should  be  replaced  at  once.  This 
can  be  accomplished  by  anointing  the  tumor  then  using  gentle, 
but  firm  pressure  against  it  until  the  sphincter  relaxes.  If  re- 
placement is  impossible,  hot  applications  or  the  use  of  a  bread 
and  milk  poultice  applied  in  the  evening  and  remaining  over 
night,  make  replacement  possible  on  the  following  day,  as  well 
as  partly  relieving  the  pain.  In  replacing  use  plenty  of  lubri- 
cant, butter  being  one  of  the  best.  Keep  the  bowels  free  and 
prevent  the  patient  from  straining  at  stool  or  standing  on  her 
feet  too  long  at  a  time.  If  pregnancy  is  the  cause  shift  the 
POSITION  of  the  gravid  uterus  and  keep  the  patient  quiet. 

If  the  hemorrhoid  remains  external  very  long,  its  walls 
thicken  and  there  is  formed  the  chronic  pile,  which  is  fibrous  in 
character,  irreplaceable  and  produces  little  trouble. 

CONSTIPATION  is  also  a  common  complication  of  diseases 
of  the  female  genitalia.  There  are  several  anatomical  explana- 
tions for  this.  The  nerve  supply  of  the  levator  ani  muscle,  the 
rectum,  vagina  and  uterus  is  very  closely  connected.  On  this 
account,  a  diseased  condition  of  one  is  likely  to  affect  the  other. 
A  general  relaxation  is  the  common  condition.  The  mucous 
membrane  and  sphincters  prolapse,  the  lumen  of  the  bowel  thus 
Vjeing  partly  closed  and  the  mucous  membrane  loses  its  irrita- 
bility, that  is  it  is  partly  paralyzed.  This  may  come  from  the 
pressure  of  a  retro-displaced  uterus.  Pressure  at  first  numbs, 
afterwards  the  bowel  prolapses.  This  form  of  displacement 
may  mechanicalh^  obstruct  the  canal,  or,  as  mentioned  before, 
an  anteverted  viterus  with  retro-position,  thus  forcing  the  cervix 
into  the  bowel,  will  produce  a  similar  effect. 

Diarrhea  sometimes  occurs  at  the  menstrual  period,  it  being 
the  result  of  the  increased  congestion  occurring  at  that  time. 
The  pressure  of  a  displaced  uterus  on  the  bowel  may  at  first  cause 
diarrhea;  later  on,  constipation. 


526  DISEASES    OF    WOMEN. 

THE  MICROBIC  ORIGIN  of  disease  is  a  subject  much  dis- 
cussed of  late.  It  is  quite  a  fad  to  attribute  every  disease  to 
some  micro-organism.  In  fact,  it  has  become  such  a  common 
thing  that  a  great  many  people  suffer  from  microphobia,  being 
in  constant  fear  of  some  dread  microbe  attacking  them.  The 
BODY  IS  PROTECTED  AGAINST  all  microbic  invasion,  if  the  skin  and 
mucous  membrane  are  in  perfect  working  order.  If  the  blood  is 
circulating  properly  and  the  skin  and  mucous  membranes  are 
intact,  no  microbe  can  enter  the  system.  Gonorrhea  will  not 
attack  a  healthy  person,  but  let  an  alcoholic  subject  be  exposed, 
or  one  that  is  weakened  by  excesses  and  it  readily  infects  the  sub- 
ject. Microbes,  then,  are  the  exciting  causes  in  the  diseases  in 
which  they  are  found,  while  the  predisposing  cause  is  a  weakness 
due  to  excesses  or  lesions  which  interfere  with  the  proper  circu- 
lation of  the  blood.  Vaginal  secretions  are  acid  and  effectually 
bar  the  entrance  of  bacteria.  Mucous  membranes  unless  they  are 
broken  are  self  cleansing  and  need  no  artificial  antiseptics. 
However,  if  they  are  abraded  an  artificial  antiseptic  is  required. 
On  this  account  and  also  from  the  fact  that  the  amniotic  fluid  and 
local  discharges  are  antiseptic,  injections  are  not  advocated  after 
delivery.  A  strong  antiseptic  injures  the  delicate  mucous  mem- 
brane and  cells  are  destroyed  by  it.  and  this  predisposes  to  the 
entrance  of  bacteria,  since  dead  tissue  is  the  best,  in  fact  the  only 
kind  of  nidus  suitable  for  their  propagation.  I  do  not  deny  the 
fact  that  microbes  are  found  in  a  great  many  diseases,  but  I  do 
deny  the  theory  that  they  are  the  cause  of  disease.  They  are  the 
result  of  disease.  Dr.  Still  once  said  to  me  that  the  "buzzard  was 
THE  BIGGEST  MICROBE  THAT  HE  KNEw".  It  feeds  ou  dead  flesh 
or  tissues;  so  do  the  microbes,  and  so  long  as  the  tissues  are  alive 
the  bacteria  cannot  affect  them,  but  so  soon  as  there  is  cell  deca--' 
they,  being  ever  present,  pounce  upon  that  part  and  there  read- 


mIk«cellaneous  affections.  527 

ily  propagate.  The  osteopathic  idea  is  to  keep  the  tissues 
HEALTHY,  thus  preventing  cell  decay.  This  is  accomplished  by 
keeping  the  blood  moving,  and  if  any  one  can  control  circula- 
tion it  is  the  proficient  osteopath. 

CARE  OF  THE  HANDS.  Since  the  osteopath  comes  m  close 
contact  with  the  patient,  the  hands  should  at  all  times  be  kept 
scrupulously  clean.  In  making  a  local  examination  see  that 
the  nails  are  pared  and  clean.  If  there  is  an  abrasion  on  the  ex- 
amining finger  use  some  other  finger  or  defer  the  examination, 
if  it  is  a  doubtful  case.  The  finger,  if  venereal  disease  or  cancer 
is  present,  should  be  protected  by  glycerine  or  a  heavy  coat  of 
vaseline. 

Always  thoroughly  cleanse  the  hands  before  treating  the 
next  patient  or  infection  may  be  transmitted.  I  have  seen  cases 
in  which  infection  was  carried  by  the  physician  on  account  of  a 
lack  of  cleanliness.  Again,  it  is  a  good  plan  to  wash  the  hands 
in  the  presence  of  the  patient  since  it  leaves  the  impression  that 
\'0U  are  cleanly.  After  treating  a  case  of  venereal  disease  be 
careful  not  to  carelessly  introduce  the  finger  into  the  eye,  or  the 
poison  may  become  transmitted  to  the  mucous  membrane  and 
produce  ophthalmia. 

RHEUMATISM.  I  have  collected  quite  a  number  of  cases 
of  rheumatism  which  were  traced  to  menstrual  disorders  as  the 
cause.  If  the  menses  are  retained  it  produces  rheumatic  symp- 
toms, such  as  soreness  in  the  muscles,  swelling  of  the  joints  with 
the  characteristic  shifting  of  the  pain  from  one  joint  to  another. 

In  some  there  were  sweats,  this  being  due  to  retention  of  the  sub- 
stances which  were  not  thrown  off  at  the  menstrual  period,  and 
the  skin  taking  on  the  function  of  additional  excretion.  In  others, 
the  symptoms  of  rheumatoid  arthritis  are  most  pronounced,  in 
fact,  I  regard  this  disease  as  due  in  most  cases  to  retention  of  the 
menses. 


528  DISEASES    OF    WOMEN. 

It  is  rare  to  get  this  disease  in  the  male  and  when  it  is  found, 
the  kidneys  are  usually  diseased.  I  have  cured  quite  a  number 
of  cases  of  initiatory  rheumatoid  arthritis  by  regulating  the  men- 
strual flow.  If  the  case  is  treated  before  the  structural  changes 
take  place  in  the  joint,  a  cure  is  almost  certain,  but  after  the  joint 
changes  have  occurred,  a  cure  is  improbable,  even  if  the  men- 
strual flow  be  regulated. 

The  treatment  should  be  confined  to  the  lumbar  and  sacral 
regions,  while  the  joints  should  not  be  manipulated  at  all,  since 
they  are  not  at  fault  and  should  be  left  alone,  or  else  they  may 
be  bruised  by  manipulation.  Strong  stimulation  over  the  lum- 
bar region  increases  the  arterial  circulation  to  the  uterus  and  is 
very  beneficial  in  menstrual  disturbances.  Bony  lesions  are 
also  fovmd  as  the  fundamental  cause  of  these  rheumatoid  affec- 
tions. 

LESIONS  OF  THE  BONY  PELVIS.  The  pelvic  bones  are  sub- 
ject to  a  variety  of  twists  or  partial  displacements  on  account  of 
the  position  of  the  pelvis,  its  function,  and  since  it  bears  the  brunt 
of  jars  and  falls,  especially  if  the  patient  suddenly  steps  into  a  de- 
pression. Some  say  that  it  is  impossible  for  the  innominate  bones 
to  be  displaced.  If  so,  why  is  there  an  increase  in  the  length  of 
one  limb  when  the  hip  is  not  dislocated?  Why  is  one  innominate 
higher  than  the  other?  Why  is  one  spine  more  prominent  than 
the  corresponding  one?  That  they  do  take  place  is  apparant 
to  one  who  has  studied  the  subject  or  to  one  that  has  cured  dis- 
orders by  correcting  the  displacement. 

If  a  lesion  does  exist,  then  there  will  be,  in  most  cases,  an 
irregularity  in  the  bony  prominences,  tenderness  at  the  articu- 
lations or  the  length  of  the  limbs  will  be  affected.  Tenderness 
AT  THE  SYNCHONDROSES  is  the  BEST  INDICATION  in  recent  cases  of 
a  slight  displacement  of  the  innominates.     Irregularity  at  the 


MISCELLANEOUS   AFFECTIONS. 


529 


symphysis  is  a  good  indication  of  a  rotated  ilium.     Shortening 

OF  THE  LIMB  INDICATES  AN  UPWARD  slip  Or  BACKWARD  rotation  of 

the  ilium.  The  sacrum  is  always  affected  by  slips  of  the  in- 
nominate bones.  A  prominent  sacrum,  indicates  a  backward 
displacement  of  the  lower  part.  A  posterior  lumbar  region  in- 
dicates that  the  upper  part  of  the  sacrum  is  posterior  and  the 
lower  part  is  anterior. 


Fui.  Ill — Sliowiug  how  the  weight  of  the  body  is  supported  by  the  pelvis. 


The  MOST  COMMON  displacement  of  the  innominate,  bones  is 
UPWARD  and  BACKWARD.  That  of  the  sacrum,  a  forward  rotation 
of  the  upper  part  and  a  backward  rotation  of  the  lower  part. 
This  can  be  more  plainly  seen  by  reference  to  Fig.  Ill,  x,  repre- 

34 


530  DISEASES    OF    WOMEN. 

sents  the  fifth  lumbar  vertebra;  s,  the  sacro-iliac  synchondrosis; 
h,  the  acetabulum;  the  three  points  are  not  in  a  straight  line,  but 
form  an  angle,  xsh.  The  force  from  below  exerted  at  h,  tends  to 
force  the  pelvis  directly  upward,  but  the  ilium  is  hinged  at  s, 
therefore,  that  part  is  moved  with  more  difficulty  than  the  sym- 
physis pubis,  and  the  force,  mstead  of  being  directed  upward,  is 
partly  directed  backward.  If  the  force  acts  on  both  hips  at  the 
same  time,  the  pelvis  is  rotated  upward  and  backward  around  the 
pivots.  On  this  account,  a  person  who  is  on  the  feet  a  great  deal, 
or  has  had  a  hard  fall  directly  on  the  feet,  usually  suffers  from 
this  kind  of  displacement.  The  points  x,  and  h,  are  approxi- 
mated, and  the  angle  xsh,  is  lessened.  The  force  from  above, 
or  the  weight  of  the  body,  is  supported  at  x,  or  the  fifth  lumbar. 
It,  like  the  force  from  below,  is  transmitted  through  an  angle, 
xsh  and  s,  is  a  pivotal  or  fixed  point  around  which  the  sacrum  ro- 
tates. Therefore,  a  force  acting  from  above  tends  to  force  x 
lower  and  by  so  doing  the  lower  part  of  the  sacrum  is  thrown 
upward  and  backward,  since  s,  is  the  fulcrum  and  xs,  the  lever. 
Each  step  or  jar  tends  to  drive  the  spinal  column  lower,  and 
if  the  muscular  and  ligamentous  supports  are  weakened  so  as 
not  to  firmly  fix  the  joints,  a  slipped  sacrum  follows. 

The  coccyx  is  a  movable  bone.  Since  the  lower  part  of 
the  sacrum  is  thrown  backward,  the  tip  of  the  coccyx  will  be 
drawn  forward  by  the  muscles  and  ligaments  attached  to  it,  and 
form  a  sharp  angle  at  the  sacro-coccygeal  articulation.  This  ex- 
plains why  a  sharp  angle  is  so  frequently  found  at  this  joint,  and 
why  the  coccyx  so  often  appears  to  be  anterior.  A  posterior 
curvature  of  the  lumbar  region  may  draw  x  backward,  thus  in- 
creasing the  angle  xsh.  In  this  case  the  upper  part  ef  the  sacrum 
will  be  drawn  backward  and  the  lower  part  forward.  Yet  the 
fifth  lumbar  ma}'  become  posterior  without  drawing  the  sacrum 


MISCELLANEOUS    AFFECTIONS.  531 

with  it,  but  it  could  not  be  thrown  anterior  without  carrying  the 
top  part  of  the  sacrum  forward,  on  account  of  the  arrangement  of 
the  articular  processes.  These  lesions  derange  the  pelvic  circu- 
lation, change  the  position  and  shape  of  the  buttocks,  and  alter 
the  length  of  the  limbs.  The  most  important  effect  is  the  direct 
interference  with  the  pelvic  circulation,  producing  menstrual 
disorders,  tumors  and  leucorrhea. 


532 


DISEASES    OF    WOMEN. 


INDEX. 


ABDOMEN,  examination  of,  108. 

Percussion  of,  112. 

temperature  of,  112. 

tenderness  of,   109. 
Abdominal  wall, subinvolution  of,  367. 

tone  of,  367. 
Abdominal  fixation,  216. 
Abdominal  pregnancy,  502. 
Abortion,  498. 

as  cause  of  disease,  86. 

causes  of,  499. 

in  endometritis,  352. 

inevitable,  501. 

sequellae,  500. 

symptoms  of,  500. 

threatened,  501. 

treatment,  501. 
Abscess  of  vulvo-vaginal  gland,  146. 
Acquired  anteflexion,  232. 
Adhesions,  peritoneal,  257,  377. 

breaking  up  of,  258. 

vaginal,  377. 
Alexander's  operation,  217. 
Amenorrhea,  397. 

causes  of,  398. 

classification  of,  398. 

drugs  in,  407. 

pathological,  404. 

physiological,  404. 

treatment  of,  406. 
Amputation  of  cervix,  332. 
Anal  fissurj,  523. 
Anus,  diseases  of  in  female,  522. 
Angina  pectori-i.  475. 


Anteflexion,  225. 

causes,  232. 

classification,  230. 

congenital,  232. 

diagnosis,  239. 

irreducible,  231. 

lesions  in,  234. 

replacement,  242. 

obstacles  to,  243. 

steriUty  in,  238. 

unequal  involution  in,  235. 

symptoms,  236. 

varieties,  230. 
Ante  version,  217. 

chronic  metritis  as  cause,  219. 

diagnosis,  221. 

replacement,  223. 

symptoms,  221. 

use  of  uterine  repositor  in,  223. 
Aphonia  in  hysteria,  483. 
Arbor  vitae,  38. 
Arrest  of  development,  80. 
Ascites, 

differentiated  from  ovarian  cyst. 

461. 
Astringents  in  hemorrhage,  310 
Atrophy  of  uterus,  383. 

BACKACHE  in  retroflexion    251 
Bartholins  glands,  26. 

abscess  of,  146. 

cyst  of,  145. 

diseases  of,  145. 

inhibition  of,  27. 


INDEX. 


5^3 


relation  to  pelvic  floor,  27. 

swelling  of,  146. 
Belt  in  fibroid  tumor,  309. 
Bimanual  examination,  123. 

object,  125. 
Binder,  objection  to,  250. 
Bivalve  speculum,  128. 
Bladder,  59. 

examination  of,  134. 

nerves,  61. 

trigone,  60. 

vessels,  61. 
Bony  pelvis,  71. 

lesions  of,  528. 
Breasts,  503. 

cancer  of,  506. 
Broad  ligaments,  46. 

contents  of,  46. 

sliape,  46. 

tenderness  in,  48. 

twisting  of,  48. 

varicosity  in,  48. 
Bulbs  of  the  vagina,  25. 
Bushwomen,  21. 

CACHEXIA  of  cancer,  320. 
Canal  of  Xuck,  19. 
Carcinoma  of  uterus,  314. 

causes,  315. 

discharge  in,  318. 

differential  diagnosis,  321 . 

hemorrhage  in,  317. 

pain  in,  139. 

signs  of,  320. 

straw  color,  320. 

symptoms  of,  general,  319. 

treatment  of,  323. 

varieties,  315. 
v^ardiac  reflexes,  474. 
Carunculae  myrtiformes,  29. 
Caruncle  of  urethra,  59. 
Cataleps}',  486. 
Causes  of  disease,  general,  76. 


Cerebral  reflexes,  472. 
Cervix  uteri, 

anatomy,  35. 

different  forms,  121. 

erosion,  335. 

laceration  of,  336. 
Chlorosis,  508. 
Civalization,  79. 
Clavus  hystericus,  483. 
Clitoris,  21. 

amputation  of,  24.  / 

blood  supply,  23. 

hooded,  21. 

inhibition  of,  23. 

nerve  supply,  24. 

stimulation,  22. 
Clitoridectomy,  24. 
Coccyx  displacement  of,  162. 
Cold  feet,  480. 
Colpitis,  154. 
Coccydynia,  172. 

Complications    of    uterine    displace- 
ment, 284. 
Constipation,  81. 

resulting  from  pelvic  disease,525. 
Congenital  anteflexion,  231. 
Corporeal  anteflexion,  230. 
Corporeo-cervical  anteflexion,  230. 
Corset,  83. 

Criminal  abortion,  87. 
Curettage  of  uterus  in  fibroids,  311. 

in  membraneous  dysmenorrhea, 

433. 
Cysts  of  vagina,  171. 

of  ovary,  460. 
Cystic  degeneration,  464. 

indications  of,  465. 
Cystitis,  221,  236. 
Cystocele,  164. 


DELAYED  menstruation,  436. 
Dermoid  cjst  of  ovary,  459. 


534 


DISEASES    OF    WOMEN. 


Development  of    female    genital    or- 
gans, 12. 

date,  12. 

differentiation  of  sex,  12. 

Fallopian  tubes,  14. 

ovaries,  13. 

Mullerian  ducts,  14. 

uterus,  14. 

uterus  bicornis,  15. 

Wolffian  ducts,  12. 
Diameters  of  pelvis,  73. 
Digital  examination,  115. 
Disease,  general  causes,  76. 

exciting,  98. 

parturition  as  cause,  99. 
Displacements  of  uterus,  187. 

general  symptoms  of,  188. 
Douches  vaginal,  174. 

effects  of,  175. 

when  indicated,  176. 
Dress,  83. 
Dysmenorrhea,  418. 

from  anteflexion,  237,  422. 

from  endometritis,  426. 

from  erosion  of  cervix,  423. 

from  faulty  development,  424. 

from  infantile  uterus,  424. 

from  lesions,  421,  423. 

from  obstruction,  422. 

from  polypi,  313. 

from  prolapsus,  197. 

from  retroflexion,  253. 

pain  in,  419. 

varieties,  420. 

membraneous,  414. 

ECTOPIC  gestation,  502. 
Education  as  cause  of  disease,  76. 
Emansio  mensium,  397. 
Endometritis,  345. 

abdominal  indications,  352. 

abortion  in,  352. 

causes,  345. 


curettement  in,  354. 

gonorrheal  type,  356. 

lesions  in,  347. 

lymphatic  glands  in,  350. 

membraneous  dysmenorrhea  in, 

350. 

menstruation  in,  349,  416. 

pathology  of,  345. 

prophylaxis,  355. 

reflexes  in,  351. 

secretions  in,  350. 

sterility  in,  351. 

uterine  displacement  in,  347. 
Epithelioma  of  uterus,  315. 
Erosion  of  cervix,  335. 
Eruption  on  face,  517. 
Examination, 

abdominal,  108. 

bimanual,  123. 

of  bladder  and  urethra,  134. 

of  pelvis,  136. 

of  rectum,  132. 
Examination  of  vagina,  114. 

of  vulva,  113. 

of  young  girls,  114. 

positions,  115. 

subjective,  105. 

with  speculiun,  127. 
Exercises  in  prolapsus,  213. 
Exposure  during  menses,  103. 
Extra-uterine  pregnancy,  502. 

symptoms  of,  502. 
Eye  strain,  513. 

FALLOPIAN  tubes, 

anatomy  of,  51. 

diseases  of,  439. 
Faulty  development  of  uterus,  424. 
Fibroid  tumors,  292. 

causes,  298. 

differential  diagnosis,  304. 

lesions  in,  299. 

pain  in,  302. 


INDEX. 


535 


physical  signs,  303. 

structure  of,  294. 

symptoms,  301. 

varieties  of,  294. 
Fibromata,  293. 
Fibro-myomata,  292. 
Fimbia  ovariana,  52. 
Fissure  of  anus,  523. 
Fistula  in  ano,  524. 
Flatus  vaginalis,  171. 
Foot,  diseases  of  in  female,  518. 
Fossa  navicularis,  24. 
Fourchet,  29. 
Frenulum,  20. 

GARRULITY  of  vagina,  171. 
Gastralgia,  470. 
Genital  corpuscles,  22. 
Genu-pectoral  position,  118. 
Globus  hystericus,  483. 
Glans  clitoridis,  22. 
Glandular  reflexes,  476. 
Glands,  mammary,  503. 
Gonorrhea,  101. 

in  female,  158. 
Goitre  from  pelvic  irritation,  477. 
Gonococci  of  Neiser,  159. 
Graafian  follicles,  55. 
Green  sickness,  508. 
Gynecological  treatment  as  cause  of 

disease,  100. 
Gynecology. 

basic  principle,  7. 

definition,  6. 

history,  7. 

HANDS,  care  of,  527. 
Headache,  467. 
Hemicrania,  468. 
Hemidrosis,  478. 
Hemometra,  403. 
Hemorrhoids,  525. 
Hemorrhage  in  polypi,  313. 


Hernia  in  female,  514. 
Heredity,  78. 
Hiccough,  473. 
Hot  flashes,  386. 
Hymen,  27. 

types,  27. 

remains,  29. 
Hysteria,  481. 

aphonia  in,  483. 

contractures  in,  483. 

eyeballs  in,  483. 

lesions  in,  484. 

sensory  disturbances,  482. 
Hysterical  temperature,  483. 
Hysperesthesia,  479.  ' 

Hystero-epilepsy,  448,  485. 
Hysterorraphy,  216. 

IMPACTED  bowel,  305. 

Infancy,  379. 

Infantile   uterus,    in    menstrual   dis- 
orders, 425. 

Inflammation  of  uterus,  340. 

Insanity,  472. 

Insomnia,  473. 

Inspection,  113. 

Intestinal  reflexes.  475. 

Interstitial  fibroid,  296. 

Intramural  fibroid,  296. 

Irregular  menses,  437. 

Irreducible  flexion,  231. 

Inversion  of  uterus,  286. 
causes,  287. 
diagnosis,  290. 
partial  305. 
symptoms,  289. 
treatment,  291. 

KNEE,  diseases  of  in  female,  518. 
Kraurosis  ^'ulvae,  151. 

LABIA  majora,  18. 
Labia  minora.  20. 


536 


DISEASES    OF    WOMEN. 


in  new  born,  21, 
Laceration  of  cervix,  326,  334. 

causes,  326. 

signs,  329. 

symptoms,  328. 

treatment,  331. 

varieties,  327. 
Laryngeal  reflexes,  471. 
Latero-flexion,  283. 
Latero- version,  283. 
Lesions  in  female  diseases,  87. 

coccyx,  96. 

rib,  90. 

sacrum,  94. 
Leucodermia,513. 
Leucorrhea,  490. 

symptoms,  492. 

in  children,  519. 

in  retroflexion,  252. 
Levator  ani  muscle,  68. 


MAMMARY  glands,  503. 

cancer  of,  506. 

diseases  of,  505. 

size,  indication  of,  504. 
Mastitis,  476. 
Masturbation,  495. 

effect  on  nervous  system,  497. 

effect  on  bowels,  497. 

symptoms,  496. 
Maturity,  381. 
Meatus  urinarius,  59. 
Membraneous  dysmenorrhea,  414,427 
Menstruation,  393. 

causes,  393. 

delayed,  436. 

disorders  of,  397. 

flow  in,  395. 

molimina  in,  394. 

sudden  cessation  of,  428. 
Menopause,  382. 


clianges  at,  383. 

dangers,  387. 

menstruation  in,  385. 

premature,  384. 

reflexes,  386. 
Menorrhagia,  409. 

abortion,  417. 

bony  lesions  in,  410. 

displacement  in,  412. 

diagnosis  of,  415. 

effects,  415. 

enteroptosis,  413. 

in  fibroids,  309. 

spinal  treatment  in,  413. 
Metritis,  357. 

acute,  364. 

abdomen  in,  361. 

bony  lesions,  357. 

in  retroflexion,  251. 

secretions,  366. 

sudden  prolapsus  as  cause,  359. 

tone  in,  359. 

uterine  displacement  in,  362. 

with  endometritis,  357. 
Metrorrhagia,  397. 

in  cancer,  317. 
Micturition,  center,  60. 

frequent,  236. 
Migraine,  468. 
Milk  leg,  517. 
Mole,  uterine.  520. 
Mons  Veneris,  18. 
Mucous  polypus,  312. 
Myoma,  292. 

NABOTHIAN  cysts,  329,  36. 
Nausea   from   displaced  ovary,   470, 

446. 
Neiser  gonococcus  of,  159. 
Nipple,  inverted,  455. 
Nuck,  canal  of,  19. 
Nymphae,  20. 


INDEX. 


537 


OBESITY  in  amenorrhea,  401. 
Occupation,  81. 
Orgasm  in  female,  22. 

seat  of,  493. 

lack  of,  509. 
Os  uteri,  36. 

Ovariotomy  effects  of,  465. 
Ovaries,  53. 

blood  supply,  56. 

congestion  of,  449. 

development  of  444. 

displacement  of,  444. 

function  of,  56. 

Graafian  follicles  in,  53. 

ligaments  of,  54. 

nerve  supply,  57. 

rib  lesions  affecting,  449. 
Ovarian  pain,  447. 
Ovarian  abscess,  458. 

colic,  430. 

cysts,  460. 

reflexes,  446. 
Ovaritis  chronic,  453. 

reflexes  in,  455. 

symptoms  of,  454. 
Ovulation,  391. 

PAIN,  419. 

Parovarium,  58. 

Palpitation     from  uterine    displace- 
ment, 474. 
Pelvis. 

connective  tissue  of,  70. 

examination  of,  136. 

floor  of,  67. 

peritoneum,  65. 

planes  of,  73. 
Pelvic  cavity,  false,  72. 

true    72. 
Perimetritis,  372. 

causes,  373. 

effects,  377. 

specific  infection  in,  373. 


symptoms,  374. 

treatment,  375. 
Perineum,  69. 

descent,  69. 

nerve  supply,  69. 
Perineal  body,  68. 
Pessaries,  43. 
Pharyngeal  reflexes,  471. 
Phlegmasia  alba  dolens,  517. 
Physometra,  403. 
Physiological  periods,  379. 
Physical  signs  of  prolapsus,  197. 
Pigmentation,  513. 
Polypus  of  uterus,  311. 

diagosis  313. 

treatment,  314. 
Polarity,  425. 
Positions,  115. 
Pouch  of  Douglas,  65. 
Precocious  menstruation,  436. 
Prepuce,  20. 
Procidentia,  187. 
Prolapsus  uteri, 

causes,  190. 

diagnosis,  195. 

effect  on  adnexa,  199. 
Prolapsus  uteri. 

prognosis,  201. 

replacement,  202. 

treatment,  201. 
Protracted  menstruation,  438. 
Pruritus  vulvae,  147. 
Puberty,  379. 

changes  at,  380. 
Pyosalpinx,  440. 

RECTOCELE,  168. 
Recto-uterine  ligament,  46. 
Rectum,  61. 

diseases  of,  520. 

examination  of,  132. 

function,  64. 

nerves,  64. 


538 


DISEASES    OF    WOMEN. 


relations  of,  62. 

structure  of,  524. 

vessels  of,  64. 
Reflex  disorders,  466. 
Retroflexion,  245. 

causes,  246. 

degrees,  246. 

lesions  in,  246. 

replacement  of,  258. 
Retroversion,  269. 

causes,  270. 

degrees,  269. 

diagnosis,  275. 

symptoms,  274. 

treatment,  276. 

replacement,  277. 
Rheumatism,  529,  478. 
Rheumatoid  arthritis,  530,  478. 
Rima  pudendil  19. 
Round  ligament,  49. 

SACRO-ILIAC  articulation,  74. 
Sacro-coccygea  articulation,  74. 
Sacro-uterine  ligament,  44. 
Salpingitis,  440. 

acute,  440. 

chronic,  442. 

gonorrheal,  441. 
Sarcoma  of  uterus,  324. 
Scanty  menstruation,  408. 
Sciatica,  511. 

in  retroflexion,  251. 
Senility,  390. 
Sim's  position,  117. 
Sound,  209. 

Speculmn,  examination  with,   127. 
Spinal  irritation,  479. 
Spinal  colvunn  in  tumors,  299. 
Stenosis  of  os,  434. 
Stem  pessar}-,  214. 
Sterility,  86,  488. 

in  retroflexion,  253,  489. 

lesions  in,  489. 


Stomach  disorders,  469. 
Subinvolution, 

laceration  in,  367. 

lesions,  366. 

nursing  in,  367. 

symptoms,  368. 
Submucous  fibroid,  295. 
Subperitoneal  fibroid,  297. 
Subjective  examination,  105. 
Supports  of  uterus,  211. 
Suppressio  mensium,  397. 
Superinvolution,  371. 
Sweat  glands,  478. 

TAMPONS,  215. 

Torsion  of  uterus,  284. 

Tonsils,  471. 

Trachelorraphy,  331. 

Traumatism  as  cause  of  disease,  103. 

Trendelenburg  position,   119. 

Tumors  of  uterus,  292. 

classification,  292. 

definition,  292. 

fibroid,  292. 

curettage  in,  311. 

diagnosis  of,  305. 

operations  in,  310. 

prognosis,  306. 

rest  treatment  in,  308. 

treatment  of,  306,  311. 

ULCERATION  of  cervix,  339. 
Unequal  development  of  uterus,  235. 
Urethra,  58. 

examination  of,  134. 
Uterus  bicomis,  15. 
Uterine  mole,  518. 
Uterine  repositor,  206. 
Uterus,  34. 

arbor  \ntae,  38. 

blood  supply,  40,  341. 

body,  37. 

cavity,  37. 


INDEX. 


539 


cervix,  35. 
endometrium,  39. 
glands  in,  39. 
ligaments,  42. 
lymphatics  of,  41. 
mobility,  34. 
nerves,  41. 

normal  position,  179. 
OS  externum,  36 
parts,  34. 
relations,  178. 
size,  34. 
supports,  183. 
walls,  39. 

VAGINA,  29. 

blood  supply,  33. 
examination  of,  114. 
fomices,  39. 
function,  32. 
lymphatics,  33. 
nerves,  33. 


rugae,  31. 
Vaginal  examination, 

things  to  be  noted  in,  120. 
Vaginal  secretions,  155. 
Vaginismus,  161. 
Vaginitis,  154. 

sjTnptoms,  159. 
Varicose  veins  of  vulva,  151. 
Vesico-uterine  ligament,  43. 
Vestibule,  24. 
Vicarious  menstruation,  434. 

forms,  435. 

treatment  of,  435. 
Viilva,  examination  of,  113. 

injuries  of,  153. 
Vulvitis,  140. 

causes,  140. 

symptoms,  142 

treatment,  144. 

WOLFFIAN  bodies,  12. 
Wire  uterine  repositor,  263. 


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